Stanford UniversityKing Center on Global Development

Understanding The Health Impacts of and Response to COVID-19 in Africa

Agnes Binagwaho, M.D., M(Ped), Ph.D.Vice Chancellor, Professor of Pediatrics, University of Global Health Equity

Senior Lecturer, Department of Global Health and Social Medicine, Harvard Medical SchoolClinical Professor of Pediatrics, Geisel School of Medicine at Dartmouth

Senior Advisor to the Director General, World Health OrganizationTwitter @agnesbinagwaho

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OverviewMain objective: Examine the impacts of COVID-19 on health outcomes and health systems in Sub-Saharan Africa compare to US and Europe and the contributors to the pandemic response.

Structure: ● Provide an overview of the status of COVID-19 cases in Africa and

compare to the US and Europe.● Discuss the impacts on African health systems and health workers and

compare to the US and Europe.● Examine the colonial mentality with regards to Africa’s response.● Explore contributors to Africa’s preparedness and response: Lessons learned

from Rwanda.● Provide an overview of the challenges faced by African countries.

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European Centre for Disease Prevention and Control, 2020

COVID-19 situation update worldwide, as of 2 September 2020. European Centre for Disease Prevention and Control. Accessed September 2, 2020. https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-casesTotal confirmed COVID-19 deaths. Our World in Data. Accessed September 8, 2020. https://ourworldindata.org/grapher/total-covid-deaths-region

Distribution of COVID-19cases worldwide

COVID-19 situation update worldwide, as of 2 September 2020. European Centre for Disease Prevention and Control. Accessed September 2, 2020. https://www.ecdc.europa.eu/en/geographical-distribution-2019-ncov-casesTotal confirmed COVID-19 deaths. Our World in Data. Accessed September 8, 2020. https://ourworldindata.org/grapher/total-covid-deaths-region

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Distribution of COVID-19 deaths worldwide

The State of the Pandemic in Sub-Saharan Africa

5Africa CDC - COVID-19 Daily Updates. Africa CDC. Accessed September 16, 2020. https://africacdc.org/covid-19/Mortality Risk of COVID-19 - Statistics and Research. Our World in Data. Accessed September 13, 2020. https://ourworldindata.org/mortality-risk-covidAfrica: Covid-19 - Continent’s Low Death Toll Explained - allAfrica.com. Accessed September 13, 2020. https://allafrica.com/stories/202008160034.html

Wrong predictions • Self indulgence.• Currently: 1,365,689 cases.• Lower confirmed case-death rate

in Africa. • Africa: 2%, North America:

4%, Europe: 6%.Avoid the single story for Africa• Rwanda ≠ South Africa, Egypt• Italy ≠ Norway

Impacts on Health Systems in sub-Saharan Africa

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Increased stress on health systems worldwide. • Italy • US

Higher risks in developing world. • Rwanda• South Africa

Tshwane District Hospital in Pretoria, South Africa, CGTN News, July 10, 2020

Two professionals comforting each other in the ICU of a hospital in Cremona, Italy, Paolo Miranda, March 2020

New York's healthcare workers are on the frontlines of the US war against Covid-19, BBC, April 2020

Healthcare workers at Kanyinya treatment center, Rwanda Broadcasting Agency, March 2020

Impacts on Health Workers and Health services in sub-Saharan Africa

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Over 10 000 health workers in Africa infected with COVID-19. WHO | Regional Office for Africa. Accessed September 8, 2020. https://www.afro.who.int/news/over-10-000-health-workers-africa-infected-covid-19CDC. Coronavirus Disease 2019 (COVID-19) in the U.S. Centers for Disease Control and Prevention. Published March 28, 2020. Accessed September 16, 2020. https://covid.cdc.gov/covid-data-trackerHealth workers bear brunt of COVID-19 infections | EPSU. Accessed September 14, 2020. https://www.epsu.org/article/health-workers-bear-brunt-covid-19-infectionsIn WHO global pulse survey, 90% of countries report disruptions to essential health services since COVID-19 pandemic. Accessed September 8, 2020. https://www.who.int/news-room/detail/31-08-2020-in-who-global-pulse-survey-90-of-countries-report-disruptions-to-essential-health-services-since-covid-19-pandemic

WHO, July 20201

Compromised safety, increased responsibilities.• 10,000 health workers in Africa infected as of July 23. • US: 160,000+ (as of September 15), Europe: 150,000

infections in only 9 European countries (as of July 3).Disruption of healthcare services • Increase in deaths caused by other diseases worldwide. • 90% of countries reported a disruption in services.

Widening of preexisting health disparities.• The poor are left worse off.

• Vaccination, delivery. UN, March 2020

Impact on Health Systems: Comparison with the US and Europe – regions that are better equipped

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Overburdened health system and healthcare workers worldwide.• Shortage of PPE in the US and Europe. • Equipment bought by vulnerable countries and stolen by the powerful ones. • CDC Africa pooled procurement (issues due to powerful countries 'need).

Disruptions in healthcare services across the globe.• England: postponement of cancer services is projected to cause 18,000 deaths/yr. • In Africa, where there are few cancer services, new progress was slowed down.

Deepening of inequities worldwide.• Black people in the US comprise 13% of the population but make up 30% of

COVID-19 cases. Studies need to be conducted in Africa – we don’t know.• Health insurance tied to employment in the US. In African countries, few have

health insurance. COVID-19 and Behavioral Health Disparities for Black and Latino Communities in the U.S. Samhsa. Accessed September 9, 2020. https://www.samhsa.gov/sites/default/files/covid19-behavioral-health-disparities-black-latino-communities.pdfThe hidden health crisis of COVID-19 in Europe | McKinsey. Accessed September 9, 2020. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/understanding-and-managing-the-hidden-health-crisis-of-covid-19-in-europe#

Western Supremacy Mentality withregards to Africa’s response

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Expectation that Africa will fail in our response • Expected 10million COVID-19 deaths in Africa.• Need new metrics in global health.• Global Health Security Index: the US as the most prepared country.

• Challenge: Lack of research capacity in Africa to tell our own story.Focus on our limitations as factors of response• Lack of testing etc.. instead of factors of success.• Lack of testing and denial in some countries and might be linked to non-

scientific reasons? (e.g. elections in Tanzania and the US). The North-South paradigm • “Solutions originate from the North”.• Refusal to learn from the south except when presented by a “Western savior”.

Binagwaho, A., Frisch, M.F., Ntawukuriryayo, J.T. and Hirschhorn, L.R., 2020. Changing the COVID-19 Narrative in Africa: Using an Implementation Research Lens to Understand Successes and Plan for Challenges Ahead. Annals of Global Health, 86(1), p.104. DOI: http://doi.org/10.5334/aogh.3001The Global Health Security Index. GHS Index. Accessed September 9, 2020. https://www.ghsindex.org/Pulejo M, Querubín P. Electoral Concerns Reduce Restrictive Measures During the COVID-19 Pandemic. National Bureau of Economic Research; 2020. doi:10.3386/w27498Adam A. Tanzania presidential election to be held on October 28. Accessed September 15, 2020. https://www.aljazeera.com/news/2020/07/tanzania-presidential-election-held-october-28-200721100331444.html

Global Health Security Index, 2020

Contextual factors Barriers ● Transport across country,

transit hub, commerce ● Access to running water● Spread of the disease● Financial instabilityFacilitators● Strong national leadership ● Culture of accountability● Internet, mobile money

EBIs● Washing hands● Testing & contact tracing ● Quarantine, isolation● Lockdown● Border closing● Social distancing ● Focus on the truth and

cultivation of trust

Contributors to Africa’s Preparedness & ResponseLessons from Rwanda

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Key implementation strategies to implement EBIs

Use data● Review the science of the new virus generated worldwide● Daily data on disease spread in Rwanda

Integrating in policies and guidelines ● Education of health providers, population…

Border and travelers’ control ● Airport check of all passengers in January● Close land border: Tanzania, Uganda, RDC

Multisectorial coordination ● Immigration, police, local government, education

Maintain focus on primary care (MCH, vaccinations)11

Promotion of Innovation ● Drones, robots Accountability● Local leaders, Head of villages to implement policiesStrength of Health Sector, including community health ● Education of health professionals, CHWs and the populationFocus on equity● Providing food, free testing, quarantine & treatment Providing financial and facilities support● Reduce socioeconomic hardships, bank, renting

Key implementation strategies…

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However, amidst this crisis…

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Rwanda is showing promising trends in health services coverage.• Severe malaria dropped by 38% in Rwanda.• Maternal health services.

Rwanda: Severe Malaria Drops by 38% in Rwanda- allAfrica.com. Accessed September 14, 2020. https://allafrica.com/stories/202009120361.html

Moving forward

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We can’t simply wait for the vaccine. We need to:• Track emerging contextual factors.• Continue implementing the known EBIs. • Support the most vulnerable in our communities.• Innovate ways to reduce spread and provide care.• Be flexible and prepare for any scenario. Build partnerships based on mutual respect.• Learn from each other, respect human rights and share

knowledge:• E.g. International COVID-19 Data Research Alliance

Rely purely on facts and scientific evidence • Avoid politically motivated statements.

Bioworld, 2020

International COVID-19 Data Research Alliance, 2020

International COVID-19 Data Research Alliance and Workbench. HDR UK. Accessed September 9, 2020. https://www.hdruk.ac.uk/covid-19/international-covid-19-data-alliance/

Challenges faced by African countries

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Gross Domestic Product, 2nd Quarter 2020 (Advance Estimate) and Annual Update | U.S. Bureau of Economic Analysis (BEA). Accessed September 16, 2020. https://www.bea.gov/news/2020/gross-domestic-product-2nd-quarter-2020-advance-estimate-and-annual-updateSenegal trials begin for $1 COVID-19 test kit. Accessed September 14, 2020. https://www.aljazeera.com/news/2020/04/senegal-trials-1-covid-19-test-kit-200428132313740.htmlEurozone suffers deepest contraction on record - BBC News. Accessed September 14, 2020. https://www.bbc.com/news/business-53606101https://www.hsph.harvard.edu/news/press-releases/poll-half-of-households-in-the-four-largest-u-s-cities-new-york-city-los-angeles-chicago-and-houston-report-facing-serious-financial-problems-during-the-coronavirus-outbreak/

Economic threat• Unemployment is worsened by COVID-19 (same in other continents)• Half of households in the four largest U.S. cities are facing financial problems

• Large informal sector• Economy is contracting by 7-8% (US: 32.9% , Europe: 11.9%)

Difficulty of contact tracing • Cross border traveling of humans and goods• Limited number of testing centers and contract tracing capacity

Limited research and health services capacity• Lack of strong research capacity to develop testing tools or a vaccine• Senegal is challenging this: $1 COVID-19 test kits are in the testing phase

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Thank you!