As reports begin to emerge that Southern Africa is slowly coming out of the woods in the Covid-19 pandemic, there is a growing optimism that life could slowly be going back to normal. The statistics are as confusing as they are potentially enlightening. “We are seeing that we have had what seems to have been a peak, and now we have the daily numbers of cases being reported overall in the [Africa] region going down,” the World Health Organisation Africa regional director Matshidiso Moeti is reported to have said recently.

However, tracking the arc of the virus in Africa has been and remains a challenge. Could it be possible that the continent has actually passed its Covid-19 peak? Can anyone now or in the near future speak with conviction of the true toll of Covid-19 on the continent?

In this article, we discuss the trends and statistical enigma, and we encourage readers to understand that the “positive” news of Covid-19 easing and the return to normalcy should be treated with some degree of caution.

Poor data management or just a Covid-19 enigma?

Africa has been plagued by poor data management, inadequate testing – including its gendered dimensions – poor information dissemination as well as general flaws underpinned by a lack of detail and consistency in the data itself. This has resulted in some cases of disconnection between governments and experts on the true status of Covid-19 statistics in Africa. This has the potential to scamper robust solutions for this and other pandemics in future.

Demographers, who have studied population dynamics and the social determinants of health in various African contexts, say they are concerned that weaknesses in data collection and collation may make it more difficult to tailor solutions for those most vulnerable to Covid-19.

For example, the governments of several African countries have been reporting counts of confirmed cases, recoveries and deaths related to Covid-19, without a breakdown by age and sex. That information is vital to help governments make more effective decisions about more targeted interventions.

When Covid-19 broke out, there were predictions that Africa would face decimation when the virus got to its peak. This was due to the reality that public health infrastructure in many African countries is not developed to accommodate the large influx of severely sick people needing intensive care. However, the infection and mortality rates have been so low compared to other regions that this has raised more questions than answers.

While acknowledging that reliable data is not always easy to come by and figures are likely to change, scientists observe that “even if deaths have been under-reported here – perhaps by a factor or two – South Africa has still performed impressively well, as have many other parts of the continent”. Many hospital beds remain empty, and infection graphs have not reached peaks seen in so many other parts of the world. This puzzle about Covid-19 statistics and Africa left Professor Salim Karim – widely seen as a leading voice on the pandemic response in South Africa and across the continent – with this to say: “Most African countries don’t have a peak. I don’t understand why. I’m completely at sea.” While Professor Shabir Madhi said: “This is an enigma. It’s completely unbelievable.”

Testing and data reliability

By far, the single most important factor that casts doubt on the reliability of official figures stems from testing. Cost aside, most governments across the continent are too poor or conflict-ridden to carry out widespread testing, while others are reluctant to share data or to expose their crumbling health systems to outside scrutiny. As a result, 10 countries account for 80% of Covid-19 testing in Africa, according to the Centre for Disease Control.

Researchers Francis Kobia and Jesse Githaka instructively point out that the extent to which governments roll out testing for surveillance has been dependent on each country’s prevailing circumstances and preferred Covid-19 control strategy. They point out how most African countries face numerous challenges in their efforts to diagnose suspect cases, trace contacts for further testing and roll out surveillance testing.

The director of the Africa Centres for Disease Control and Prevention (Africa CDC), Dr John Nkengasong, said that in mid-May 2020, only 1.3 million tests had been conducted across the continent. This translates to a continental average of one test per 1,000 people. There are, however, huge discrepancies between countries. Smaller and wealthier nations, like Mauritius, have some of the highest rates, even by global standards.

It must be emphasized from the onset that Covid-19 testing is a costly process whose bill most governments failed to pay or attempted to avoid altogether. Without outside help, the majority of countries in the region claim to be helpless.

In a previous article, we have shown how even this weakened testing capacity has been further decapitated by massive corruption. Yet the best-proven strategy is vigorous mass testing and effective contact tracing which covers a large portion of the population.

Yet, according to Nkengasong, only South Africa, Egypt, Nigeria, Ghana, Morocco, Kenya, Ethiopia, Rwanda, Uganda and Mauritius have conducted more than 200,000 tests.

A closer look reveals that these are countries with stronger economies and more stable governments. 

Below, we contrast several country responses to illustrate this argument. 

Mozambique

Surveys conducted in August 2020 in Mozambique found antibodies to the virus in 5% of households in the city of Nampula and 2.5% in the city of Pemba. According to National Institute of Health Director Ilesh Jani, the Mozambique antibodies surveys detected the virus in all neighbourhoods in Nampula and Pemba.

The groups with the highest exposure to the virus were market vendors at 10%, followed by health professionals at between 5.5% and 7%, police at between 3.7% and 6%, and shop and other business employees at between 5% and 5.5%. Concern was raised as to whether more people had been infected than official numbers show.

“We don’t know why more are not being hospitalised. In Nampula, we thought we would see more mortality, but there has been no increase in deaths,” reported Jani.

Similarly, an epidemiological survey recently undertaken in Maputo by the National Health Institute (INS) shows that 3.79% of the capital’s residents have Covid-19 antibodies. According to the report, the test does not show whether the person concerned currently has Covid-19 – but it does show the presence of antibodies to the virus, indicating that the person has been infected in the recent past.

It was revealed that every urban district showed exposure to Covid-19, with the highest rates found in Nlamanculo (4.72%), Kamabukwana (4.53%) and Katembe (4.48%). The highest exposure to Covid-19 was reportedly found among those over 60 years old (4.48%), followed by young adults, in the 15-34 age group (4.42%), and children under the age of 15 (3.25%).

If those numbers were extrapolated to the entire population of Mozambique – home to about 30 million people – the country would have far more cases than the 4,207 reported as of 4 September 2020. 

Tanzania

Perhaps the more interesting case is that of Tanzania whose failure to do mass testing is less about capacity than it is about democracy. The increasingly authoritarian President John Magufuli rather bizarrely ordered the testing to cease. Magufuli has already declared the scourge “absolutely finished” and encouraged tourists to come back to his country.

However, footage posted online during the pandemic showing night-time burials have raised serious questions about the severity of the outbreaks experienced. Magufuli declared a thanksgiving period to celebrate a decline in the number of infected people, despite significant numbers of positive cases continuing to be detected along its borders with Kenya and Zambia.

In response, neighbouring countries have announced border closures, fearing an upsurge in imported cases.

Most bizarrely, the government decided to stop reporting Covid-19 statistics. The World Health Organisation last heard from Tanzania on 29 April 2020, when the country reported 509 cases and 21 deaths from Covid-19, in what would be a strikingly high death rate. The president has said releasing the figures was causing unnecessary panic.

As early as May 2020, there were major fears of a cover-up over the Covid-19 death toll. “Right now, we are witnessing a lot of mourning, burials and dead bodies everywhere. Without transparency, the citizens will be more scared, which may cause even more deaths,” opposition leader Zitto Kabwe said.

The government has continued to marginalise testing labs and led a crackdown on anyone who dares raise concerns about the virus’s spread, or the government’s response to it.

Critics have been arrested, and opposition politicians and human rights activists say their phones are being tapped.

Dr John Nkengasong of the CDC told the BBC that there is not enough data coming out of Tanzania to know how Covid-19 is being dealt with. “We continue to hope and plead that Tanzania could come forth and report the situation as it is so that we can work collaboratively to stem this virus out of the continent.” 

Zimbabwe

In Zimbabwe, the capacity to effectively fight the pandemic, to increase testing and get accurate statistics is diminished by poor governance and systemic corruption.

The Standard, a weekly local newspaper, revealed how the country was ill-prepared to tackle the pandemic as there was no plan, no equipment, no drugs and no staff. Upon realisation that they had no capacity to test, trace cases and contain the situation, it is alleged that authorities resorted to lying to save face. 

The exorbitant fees being charged for access to healthcare has worsened the situation. Medical and Dental Private Practitioners of Zimbabwe Association interim president Johannes Marisa recently told The Standard:

“With the unavailability of affordable and easy testing, many people are going for long without being detected of Covid-19, making it a life-threatening risk on the part of the private practitioners, who have lately assumed the number one position on the frontliners list,”.

The few private Covid-19 centres, though operating with limited staff and poor protocols, are reportedly charging admission fees of between US$3,000 and US$5,000 for patients who have tested Covid-19 positive.

The phenomenon of using the legal system as an instrument for pre-trial punishment of human rights activists and legitimate political opponents has also brought focus on the unreliability of Covid-19 statistics in Zimbabwe. 

The incarcerated opposition Member of Parliament for Zengeza West constituency, Job Sikhala gave a picture of the “grim conditions prevailing at Chikurubi Maximum Security Prison where he alleged that prisoners were dying after contracting Covid-19 while detained at the notorious prison”.

Sikhala’s claims were buttressed by other incarcerated political prisoners, journalist Hopewell Chin’ono and opposition political leader Jacob Ngarivhume, who also saw first-hand the situation in Zimbabwe’s prisons after 45 days in the country’s two big prisons, Harare Central Prison and Chikurubi Maximum Prison. In separate interviews soon after their release on bail, they both confirmed the prevalence of Covid-19 in the prisons where inmates are crammed and overcrowded. Prisoners do not have adequate Covid-19 information or personal protective equipment such as masks. Without medication, those who are suspected of being infected are simply isolated and treated only with warm drinking water.

South Africa

South Africa, the Covid-19 epicentre of Africa has been reporting a reduction in infections over the past few weeks. As of 6 September 2020, South Africa had recorded a total of 636,884 infections and 14,779 deaths.

Across the continent, just over 1.1 million cases have been reported, with 22,883 deaths.

With its two most affected provinces, Western Cape and KwaZulu-Natal recording significantly fewer and fewer cases, there is a great deal of optimism that the worst may be over. There is increasing talk of the curve having been flattened with reports indicating the number of daily infections having fallen from a peak of 13,000 during July 2020 to less than 2,000 as of 31 August 2020.

“We can say we are over the surge. The plateau has started,” the country’s Health Minister, Zweli Mkhize said.

However, while these figures make for some good reading, it is also important to bear in mind the reports of a significantly increased number of people dying from “natural causes”. Researchers believe that the real number of actual Covid-19 deaths could be much higher than official statistics suggest. 

Richard Lessells, an infectious disease specialist at the KwaZulu-Natal Research Innovation and Sequencing Platform in South Africa, is reported to have said the figures were not surprising because the same pattern could be seen in other countries.

It could partly reflect other knock-on effects in the health system, such as “if I have a stroke at home and my family decides they don’t want to take me to hospital because it’s too risky and I die at home”.

It therefore should come as no surprise that the Medical Research Council in South Africa has found a “huge discrepancy” between the country’s confirmed Covid-19 fatalities and the number of excess natural deaths, providing further evidence that the number of people who have perished from the disease may be higher than the government reports. 

Conclusion

The notable decrease in cases in the region, especially in South Africa, which has been the epicentre of the pandemic in Africa, comes as a very welcome sigh of relief. Nkengasong said that there were signs of hope that “we are beginning to bend the curve slowly”.

Yet, this relief must be tempered by the fact that the true extent of the pandemic in the region is unknown and may remain unknown in the absence of reliable data and statistics. In some countries, as we have shown, the politicisation of the pandemic has made it difficult for data collection and synchronisation. It has robbed the region of hard knowledge and facts that could be useful in the building of more robust systems that can better confront Covid-19 and the next pandemic. As Emmanuel Olamijuwon, Fidelia A. A. Dake and Oluwaseyi Dolapo Somefun report, “flaws in the collection of African population statistics block Covid-19 insights”. DM/MC

Arnold Tsunga is a human rights lawyer and the technical and strategy adviser of the SAHRDN. Tatenda Mazarura-Mhike is a woman human rights defender (WHRD), a professional rapporteur and an election expert. Mark Heywood is editor of Maverick Citizen.