Could West Africa’s experience with Ebola help it combat COVID-19?
rom late 2013 to 2016 the world looked on as Guinea, Liberia and Sierra Leone suffered the worst ever recorded outbreak of Ebola. The highly contagious virus, which makes its victims bleed from every orifice, infected at least 28,600 people and killed 11,325. The world looked on in horror as it struggled to comprehend the devastation wrought by the disease, which tore apart families, communities and livelihoods.
Now the world is beginning to understand what such an epidemic feels like. As of 27 March, there are 540,832 reported coronavirus cases and 24,293 deaths globally. While the first case of COVID-19 occurred in China in December 2019, and the US and Europe have since become the new epicentres of the crisis, the African continent has been relatively unaffected to-date. China has suffered some 3,292 deaths and the worst-affected country in Europe - Italy- has seen 8,251 people die of the virus, but so far there are only 13 recorded deaths in West Africa and wider Sahel: seven in Burkina Faso, two in Cameroon, and one in Gabon, Niger, Nigeria, the Gambia respectively.
The African continent appeared to be so untouched by the virus in the early days of its proliferation that some West Africans joked that black skin protected the region’s inhabitants from contracting the virus. But such quips seem less funny now as the number of confirmed cases in Africa as a whole tripled from 450 to 1,485 in the week to 23 March. Sierra Leone is now the only country in West Africa not to have confirmed a single case of the disease. As it becomes clear that West Africa will be increasingly infected by coronavirus, the question arises of whether the 2013-2016 Ebola epidemic stood the region in good stead for tackling the world pandemic of COVID-19.
Prevention is better than a cure
Prevention has thus far been the key to West Africa’s response to coronavirus. In large part as a result of the experience that the region had with Ebola, prevention measures are readily available and easily implemented, with many presidents acting much faster than their European counterparts. Italy waited until it had confirmed hundreds of deaths before implementing a nationwide lockdown. By contrast, West African nations have been rapid to close their airports, prevent inbound and outbound flights and ban public gatherings of more than 50 people. Even countries, like Mali, which has only documented four cases of coronavirus as of 27 March, have closed schools and universities and suspended flights from affected countries.
"So far there have only been 13 recorded deaths in West Africa and wider Sahel: in Burkina Faso, Cameroon, Gabon, Niger, Nigeria and the Gambia.
Thermal sensors have been introduced at borders to check for the tell-tale high temperature that many coronavirus patients exhibit, further proof of the lessons learned from the Ebola crisis. Then, such mechanisms were put in place to halt the scourge and proved instrumental in containing the virus to just three countries in the region.
Equally, there are some highly effective communication strategies already in action in countries like Liberia, where fake news and mistrust of authorities posed serious challenges to combatting Ebola. Fact-checking websites, radio stations and TV channels are already in existence there to halt the dissemination of misinformation regarding the disease. The rapid introduction of such measures is testament to the seriousness with which governments in the region take health crises, as well as a recognition that with limited health facilities available in the region, prevention is far better than a cure.
Although it is impressive that West Africa has responded so quickly and prudently to the spread of COVID-19, many challenges lie ahead. Importantly, prevention is now no longer sufficient, since the disease has entered West African territories and is already affecting hundreds of people.
Stopping the spread is now crucial, but this will be more difficult. Basic measures that have been used in Europe to contain the contagion, albeit belatedly, such as excessive handwashing and self-isolation are much harder to implement in West Africa, where running water is a luxury and many residents live in slums in extremely close proximity to others. These conditions provide an ideal breeding ground for the virus.
Additionally, how will authorities prevent people using crowded public transport to get to work when there are no other means of getting around and residents have to work to feed their families? Most governments in the region will not be able to implement sufficient security packages to enable citizens, largely employed in the informal economy, to stay away from their jobs. What will be the point for residents in staying home to avoid catching the disease, if they starve instead?
It is true that these challenges existed in the time of the Ebola epidemic as well, but authorities were, eventually, able to quarantine infected patients and trace contacts with which infected persons had come into contact. This was extremely difficult however, and took months, particularly as trust in public health was low and quarantines were often implemented in draconian ways. Having recently experienced Ebola, West Africans may be more willing to accept the need for such measures again now.
The problem however, will be that so many cases of coronavirus are asymptomatic. Recent studies show that around 17 percent of COVID-19 patients do not show symptoms. Many others have only mild symptoms or they only show up several days after they have already contracted the disease. This is in stark contrast to Ebola which makes patients very sick, quickly. In this sense, tracing and isolating cases of Ebola was far simpler.
The haemorrhagic fever is also a much deadlier, more overtly unpleasant virus, prompting restrictions on movement to be more effective because people fear having the disease. Coronavirus may not have quite the same aura. In the UK, for example, there has been resistance to crackdowns on freedom of movement by young people who are not bothered by catching the “flu”.
Preventing the spread of coronavirus in tightly packed communal living quarters, where running water is scarce, and people are forced to continue to go out to work every day is deeply problematic. Perhaps the positive aspect of this challenge, however, is that, unable to rely on social distancing measures introduced with some efficacy in Europe, West African governments may be forced to focus on testing large numbers of residents to prevent the disease spreading. This has proven extremely effective in halting the spread of coronavirus in South Korea, which has one of the world’s lowest fatality rates from coronavirus, at just 1 percent.
Such vast testing might be challenging in West Africa, where medical resources are less plentiful. Nonetheless, since Ebola, the African continent has significantly improved its laboratory capacity and there are now at least 20 countries which have access to COVID-19 testing facilities. This is important, given that one of the major delays in tackling Ebola in 2013-2016 was the sluggish pace of testing. The first tests undertaken in Liberia for Ebola took two months to return from a facility in Lyon, France. Those 60 days were invaluable lost time in combating the epidemic.
Structural factors may also play a role in how efficacious West Africa’s response to coronavirus is. The region has an overwhelmingly youthful population with a median age of 18, compared to 45 in Italy, where the virus has decimated the elderly population, for whom the disease is more frequently fatal. With so few aged West Africans, this could help the region escape the high death tolls witnessed in other parts of the world.
The region is less fortunate in other ways though. Underlying conditions, which are also thought to increase the probability of coronavirus being deadly, are prevalent in the region. Diabetes, HIV and malaria are widespread, while other outbreaks occur regularly. Nigeria is currently struggling to contain a severe Lassa Fever outbreak, for example, which will diminish the resources it has to deal with COVID-19.
"Diabetes, HIV and malaria are widespread, while other outbreaks occur regularly. Nigeria is currently struggling to contain a severe Lassa Fever outbreak, which will diminish the resources it has to deal with COVID-19."
Importantly, whereas during Ebola , West Africa received considerable international support, this may not be quite so immediately forthcoming during the COVID-19 pandemic. In 2013-2016, the world looked at West Africa in despair at the destruction caused by Ebola, but now the whole world is suffering at the hands of this virus, that developed countries scarcely have sufficient resources to help their own victims. Convincing them to provide aid to West Africa in the way they did during Ebola will be challenging.
Additionally, health facilities are already overstretched. Should the virus reach the proportions seen in Europe, the region will really struggle to help patients. Mali, which has a population of 20 million has just 20 ventilators at its disposal, leaving it woefully ill-equipped to deal with such an aggressive respiratory disease. Healthcare workers are also in limited supply, a problem exacerbated by frequent medical employee strikes. Nigerian doctors in Abuja launched industrial action over a failure to pay wages on 19 March, just as the country announced its 12th confirmed case of coronavirus.
Finally, while Ebola spread in three West African nations, these were all countries at peace. Sierra Leone, Liberia and Guinea faced no ongoing civil wars or rebellions and, although state presence and public health facilities were weak in parts of these countries, these could be boosted during the crisis, especially with international assistance. Since that outbreak, West Africa has increasingly struggled to combat a growing Islamist extremist insurgency, notably in Burkina Faso, Mali and Niger, recently expanding slightly into coastal countries as well. Such security threats make establishing more effective state presence and medical facilities in remote parts of the country extremely difficult, while also severely threatening any attempt to report, isolate and trace contacts of the sick. Facing up to raging insecurity while also tackling a highly contagious virus could yet be one of the most challenging aspects of dealing with this crisis in West Africa.
(Main image: People walk past a graffiti on the wall depicting hygienic steps, which will be followed to struggle against COVID-19, in Dakar, Senegal on 22 March 2020 - Alaattin Dogru/Anadolu Agency via Getty Images)
The opinions expressed in this article are those of the author(s) and do not necessarily reflect the views of SAIIA or CIGI.