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Gavin: Hello, welcome to another special COVID 19 episode of The Lancet Voice. I'm Gavin Cleaver
Jessamy: and I'm Jessamia Bergenahl.
Gavin: So we wanted to take a podcast to talk about the specific problems and challenges facing Sub Saharan Africa during this COVID 19 pandemic. Of course, this is a very broad brush approach looking at so many different areas.
But to tie together some general themes, we spoke with Professor Yap Baum of Médecins Sans Frontieres, who lives in Cameroon. And he's going to try and understand the specifics of the situation in sub Saharan Africa.
Yap: My name is Professor Yap Baum, too. Working for EPICENTRE being the research arm of Médecins Sans Frontières, or Dr.
Richard Borders. I'm actually based in Cameroon, where I'm originally from. I'm a biologist by training, an engineer, actually, initially, and also an epidemiologist. I've been working in different places of the continent, in Uganda, where we have our research center in Mara, but also in Guinea. During the Ebola outbreak of 2014, 15, 16, and so on.
And then also in Democratic Republic of Congo, still on Ebola. And currently in Cameroon, working on the COVID response for the country, but also involved in what is happening in the continent of Africa.
Gavin: We really appreciate you taking the time to join us today. So perhaps we could start by just talking a little bit about the kind of unique considerations that people around the world need to bear in mind when thinking specifically about how COVID 19 will affect sub Saharan Africa.
Yap: What is quite common for Africa is at some point, a lot of people, including Africans, Thinking that the COVID will not eat us for some reason, because it has really delayed going from China to Europe and U S and. later on came to Africa. So while it was supposed to be an opportunity for most of the country and it is to get ready in time of preparedness, in term of laboratory, in term of procedure on how to prepare and respond to the COVID.
But also it bring that special thing in most of us. Believing that either the temperature will kill the virus or that we are strong enough to resist to the virus. So when you combine those kind of perception, it make more difficult the implementation of some of the measure that we have been trying to implement on how to respond to the outbreak.
The other point that I can add is since it has started, we have far to Less death as compared to what has been observed in Western countries. So which kind of let people thinking or believing that there's something special that is happening in the continent. There is some resilience. We don't know exactly where it's coming from.
There are many. Options, but definitely we think that there's something that is protecting us
Gavin: around the world. We've seen a lot of attempts to tackle COVID 19, including containment strategies like social distancing, track and trace. What's the response to? containment being like in Sub Saharan Africa?
Yap: That's a good question because Sub Saharan Africa is, there is nothing that is homogenous. You have country like Senegal, for example, that has, that's one of the first country to actually put in place a lockdown and making sure that people are protected, put in place a good surveillance system. And even now they have extended the lockdown for two extra weeks.
Actually for a month going up to June, while most of the other African countries are actually losing the lockdown. So the major measure that are still going on is the wearing of a mask, which is quite, um, systematic, at least in theory. In practice not so much people are wearing those masks, which is really a challenge.
But apart from that, you have the social distancing as much as we can. When you imagine some houses where you have five, six, even more people living in one house, how can you really implement a social distancing at home? That's a big challenge in the common place. They are trying, but the market are still full of people.
Some of them, few will wear a mask or they will not. So it's really difficult to implement those measure the way they are. They have been implemented in the West, in sub Saharan Africa. Some try, as I mentioned, a good example are Senegal, but most of the other. Countries actually struggling.
Gavin: Do you think some countries in sub Saharan Africa, their experience with Ebola containment might influence their approaches to this disease or maybe put them in a more advanced position?
Yap: Definitely in a more advanced position in the sense that they have some system in place. They have some people who have been trained on how to look for a case, how to look for people who have been in contact. So there is know how I'm talking about DRC, I'm talking about Nigeria and and some of those country, so that might be helpful.
In the other hand, if I take a country like Democratic Republic of Congo, Ebola have never hit the capital city of Kinshasa. It has been happening in some far remote province or region. So those people in those region might be more aware. Of Ebola. So not now knowing how to handle those epidemic or pandemics or those viruses.
But when you go back to the capital city where they have not really been heated, I don't think it make a huge difference. I don't think In the other hand, when you go back to West Africa, where you have Guinea, Sierra Leone and Liberia, who have been affected by Ebola in 2014, that's already five years ago.
What is the actual memory from those countries as Ebola is concerned? You may find some few of those. Some people were there before we can. Easily activate the system, but in the community, in the population still, you need to reinforce the same things. Definitely.
Gavin: So what are some things that maybe that other countries can do to ensure sub Saharan Africa comes out the other side of this pandemic without major damage?
Yap: I think research can be a game changer on what can works and what cannot works in Africa. I will just take a very simple example. In quite a number of countries including Cameroon, Senegal and so on, they are using hydroxychloroquine And as it was seen as a systematic treatment for people who are COVID positive, that is because of the result that work that came out from the professor how routine in France, but we have a different population.
The disease that how people have different. The way they will react to those drugs are also different. That's only one example. Most of the Western countries have been using molecular tests, diagnostic PCR, for example, to name them to be able to track the virus. Can we really afford that? No, maybe we cannot.
So maybe we should really find a different Algorithm, including the, for example, the rapid test. We know that they are not perfect. Definitely not. But we have to find research how we can combine them with clinic so that we can be able to screen the patient at the lower level of the community or the villages where PCR will not be implemented.
It won't. So definitely research with local level. Researcher to finding room homegrown solution are actually according to me some means that will help the sub Saharan Africa to find its own way to get out of this pandemic. Maybe the thing I would like to highlight is the resilience is really one of the message that we are getting from this pandemic.
As you may know, for having me. One big difference between Ebola and the COVID is that when we were having Ebola in our countries, we are having all the support coming from NGOs, from Western countries, in terms of money, in terms of human resource, material equipment, and so on. So this time the borders are closed, so we cannot.
Import the human resource. So we have to deal with people who are there. Secondly, also, we are not a priority. So the protective equipment will first go to Europe to us and then come to Africa. Same for the diagnostic kit. So it's also today a great opportunity for African. To produce and use the local resource, and that is an important and interesting method that is coming out of this pandemic, the African resilience.
And people making masks in different places of the continent. Some people are even trying to produce reusable protection, protective equipment, because we can't wait. For them to come from abroad. So I think I hope I think and I hope that after that they would. We will put health as our just cause and invest more on our local production of human resource and all the material that can help us to ensure that no one is left
Gavin: behind.
It's striking to hear Sub Saharan Africa's problems put so clearly there. So many thanks to Yap for talking to us about it. We also spoke with Zoe Mullen, Editor in Chief of Atlantic Global Health, to tell us a bit more about the situation.
Zoe: I guess it's not a surprise to say that in terms of challenges, many of the countries in Sub Saharan Africa are low income countries or at the very least middle income countries with poorly resourced healthcare systems.
And that's not just in terms of hospital beds and critical care capacity but human resources. So most countries in West Africa, for example, have less than five hospital beds and less than two doctors per 10, 000 population. And if you compare that with Italy say, which we all thought of as particularly overloaded in terms of its healthcare system, there are 34 beds and 10, 000 population there.
So you can immediately see the sort of the obvious challenges there. On the other hand though, Sub Saharan Africa has a very different demographic profile to Italy and the rest of Europe. Africa as a continent has a strikingly lower median population age. It's just 15 in Niger, for example, compared with Europe.
So it's 46 years is the median age in Italy. And of course the evidence is pretty clear that COVID 19 is affecting older people much more seriously than younger people. There was an article in Lance Infectious Diseases a few weeks ago showing us that case fatality rates increase. really steeply after about 60 years of age.
So if your population contains relatively few people above that age bracket, then, you're likely to see fewer deaths. However, we also know that deaths from COVID 19 are more likely in those with underlying conditions. So non communicable diseases, such as hypertension and diabetes. And unfortunately, Sub Saharan Africa is fast catching up with the rest of the world in terms of the burden of these conditions.
There's also a large burden of HIV and TB, which could also be risk factors for a more severe disease cause. So this combined with the reduced healthcare capacity suggests that the consequences could be very serious indeed.
Gavin: So you mentioned then, of course about the Ebola outbreaks in West Africa.
So of course that gives them this kind of experience of dealing with transmissible disease that's very serious for population. How do you think that experience of dealing with Ebola might? influence their containment strategies in Sub Saharan Africa?
Zoe: Yes, a good question. I guess first it's probably wise to point out that, these are two quite different beasts.
Ebola is a highly fatal, yet relatively difficult to transmit hemorrhagic fever, whereas COVID 19 is less fatal, but much more easily transmissible, and it's a respiratory illness, obviously. But the basic tenets of isolation of cases, contact tracing, and different types of behavior change to reduce transmission are certainly comparable.
I think in countries directly affected by the most recent Ebola outbreaks in West Africa, as you say, and more recently in the DRC. There's already a move to repurpose some of the Ebola isolation facilities, so that they become COVID 19 isolation facilities, and to retrain some of the healthcare workers that were trained on, donning PPE, dealing with isolated patients.
So retraining them to now work on A new beast. I think countries are also much more switched on now regarding importation events. Illnesses that come in across the borders. Many countries in Africa are now, they might require travel histories from people coming across borders, put quarantine in place.
That's all come from the experience of Ebola. And also, I think testing facilities are also a lot more advanced than they would have been if Ebola had not happened. Again, there are these sort of hubs, diagnostic. Labs available from the Ebola era that again could be re purposed to use for COVID 19 with obviously the different reagents.
I think also a lot of lessons have been learned about communication and community engagement. So some of the COVID 19 mitigation measures like Lockdowns, physical distancing, and regular hand washing are going to require the understanding and buy in of ordinary people. And the way the need for behavior change around the burial of Ebola victims, for example, the way this was initially managed was disastrous.
And that is a lesson I think that was a hard one. So this time around, I think communication will be a lot better. And finally, I think, now we have the Africa CDC. The Center for Disease Control, which was established in 2016, and it's doing a great job of coordinating the response across the continent in collaboration with WHO and other CDCs from around the world.
There are several. several aspects of the Ebola experience that can set countries up for dealing with this.
Gavin: Now you talked, of course there about social distancing, and obviously it's notable how in high income countries it's been, relatively easy for a lot of people. to socially distance, to keep, keep themselves clogged away at home, so to speak.
At Sub Saharan Africa, are there any particular challenges that when it comes to social distancing?
Zoe: Yeah, as I've mentioned, some of these requirements are going to be unfamiliar and unwelcome to people. So first of all, the communication has to be Well thought out and context specific. Otherwise people will become suspicious and potentially angry and certainly not keen to follow advice And I think in higher income countries despite the fact that you know As you say for most people it's relatively easy what we have seen and we've also seen this recently in india is that These requirements, these stay at home orders, are affecting the disadvantaged the most.
If you're already on a continent that's relatively disadvantaged, that, that's one thing, but then there, within that, there will also be people who are more disadvantaged than others. If you're living in an informal settlement, a refugee camp, or even, just a tower block in the middle of a big city, that isn't going to be a lot of fun.
You're also less likely to have simple things like running water and soap to do things like hand washing. These are going to, this is not something that's going to be as straightforward as in a higher income country. But in addition, I think, even worse with the closing of schools and social gathering places, businesses, incomes will just dry up.
The likelihood that the average sub Saharan African could work. in isolation at home is really small. And in fact the UNDP has put out an estimate that nearly half of all jobs in Africa could be lost. So that's, that's a massive thing. The International Monetary Fund and the World Bank have issued emergency funding streams, but we published a comment pointing out that these are their drawbacks and they haven't really been put together with a long term benefit to health systems in mind.
So I don't think sub Saharan Africa's. It's particularly unique in some of these challenges, but the sheer scale of the African population means that, a lot of people are going to be hurting at the end of this.
Gavin: It sounds like it really scale of population really exacerbates those particular problems.
So what are some things that other countries can do to ensure that sub Saharan Africa comes out the other side of this pandemic without really major damage?
Zoe: I think in the short term, countries need to step up and fully fund the UN's plan. COVID 19 Global Humanitarian Response Plan, so it's calling for two billion to fund things like testing materials, PPE for healthcare workers, medical equipment, but also things like light water and sanitation for food.
and vaccination against other killer diseases which could be disrupted by the COVID 19 response. This is a really obvious thing I think that countries have a responsibility to think about. And another lesson from the Ebola outbreak was not to neglect the basic needs of people in the rush to pour funding into disease specific responses.
Across the Lancet journals Already starting to see submissions, research papers on the indirect effects of COVID 19 on things like vaccination programs, maternal and newborn care and on nutrition. So something like this humanitarian response plan, which covers things like basic needs, I think is really important.
It's been depressing, actually, to see that in what's indisputably a global crisis, what could possibly be more of a global crisis than this? Nations have actually turned inwards. The U. S. president's defunding of WHO was the epitome of this. Possible long term benefit there could be from finger pointing, hoarding.
protectionism, it's really difficult to fathom. Countries become distrustful of one another and that's the last thing you want in a pandemic. In the longer term then, I think countries need to learn from each other, accept that global solidarity is the only way to manage what is likely to be actually quite a long term foe.
Jessamy: Really great to hear some context there. You've been listening to The Lancet Voice. Join us again soon.