COVID-19: Examining Theories for Africa’s Low Death Rates

Jerri-Lynn here. Two things I wish to draw to the attention of readers about this COVID-19 post about Africa.

First, India too has recorded low relative death rates, this despite reporting the world’s second incidence of cases, and having a poor health care system.

Second, the authors suggest that genetic factors may account for the lower death rates in African countries. Yet I point out that in richer countries, people of color seem to be dying at a higher rate, which suggest that the genetic explanation, if any, is not a simplistic one.

By Kevin Marsh, Professor of Tropical Medicine, University of Oxford, and Moses Alobo, Programme Manager for Grand Challenges Africa, African Academy of Sciences. Originally published at The Conversation.

As the threat of a COVID-19 pandemic emerged earlier this year, many felt a sense of apprehension about what would happen when it reached Africa. Concerns over the combination of overstretched and underfunded health systems and the existing load of infectious and non-infectious diseases often led to it being talked about in apocalyptic terms.

However, it has not turned out quite that way. On September 29th, the world passed the one million reported deaths mark (the true figure will of course be higher). On the same day, the count for Africa was a cumulative total of 35,954.

Africa accounts for 17% of the global population but only 3.5% of the reported global COVID-19 deaths. All deaths are important, we should not discount apparently low numbers, and of course data collected over such a wide range of countries will be of variable quality, but the gap between predictions and what has actually happened is staggering. There has been much discussion on what accounts for this.

As leads of the COVID-19 team in the African Academy of Sciences, we have followed the unfolding events and various explanations put forward. The emerging picture is that in many African countries, transmission has been higher but severity and mortality much lower than originally predicted based on experience in China and Europe.

We argue that Africa’s much younger population explains a very large part of the apparent difference. Some of the remaining gap is probably due to under reporting of events but there are a number of other plausible explanations. These range from climatic differences, pre-existing immunity, genetic factors and behavioural differences.

Given the enormous variability in conditions across a continent – with 55 member states – the exact contribution of any one factor in a particular environment is likely to vary. But the bottom line is that what appeared at first to be a mystery looks less puzzling as more and more research evidence emerges.

The Importance of Age

The most obvious factor for the low death rates is the population age structure. Across multiple countries the risk of dying of COVID-19 for those aged 80 years or more is around a hundred times that of people in their twenties.

This can best be appreciated with a specific example. As of September 30th, the UK had reported 41,980 COVID-19 specific deaths while Kenya, by contrast, had reported 691. The population of the UK is around 66 million with a median age of 40 compared with Kenya’s population of 51 million with a median age of 20 years.

Corrected for population size the death toll in Kenya would have been expected to be around 32,000. However if one also corrects for population structure (assumes that the age specific death rates in the UK apply to the population structure of Kenya), we would expect around 5,000 deaths. There is still a big difference between 700 and 5,000; what might account for the remaining gap?

Other Possible Contributors

One possibility is the failure to identify and record deaths.

Kenya, as with most countries, initially had little testing capacity and specific death registration is challenging. However, Kenya quickly built up its testing capacity and the extra attention to finding deaths makes it unlikely that a gap of this size can be fully accounted for by missing information.

There has been no shortage of ideas for other factors that may be contributing.

A recent large multi-country study in Europe reported significant declines in mortality related to higher temperature and humidity. The authors hypothesised that this may be because the mechanisms by which our respiratory tracts clear virus work better in warmer more humid conditions. This means that people may be getting less virus particles into their system.

It should be noted however that a systematic review of global data – while confirming that warm and wet climates seemed to reduce the spread of COVID-19 – indicated that these variables alone could not explain most of the variability in disease transmission. It’s important to remember that there’s considerable weather variability throughout Africa. Not all climates are warm or wet and, if they are, they may not stay that way throughout the year.

Other suggestions include the possibility of pre-existing protective immune responses due either to previous exposure to other pathogens or to BCG vaccination, a vaccine against tuberculosis provided at birth in most African countries. A large analysis – which involved 55 countries, representing 63% of the world’s population – showed significant correlations between increasing BCG coverage at a young age and better outcomes of COVID-19.

Genetic factors may also be important. A recently describedhaplotype (group of genes) associated with increased risk of severity and present in 30% of south Asian genomes and 8% of Europeans is almost absent in Africa.

The role of these and other factors – such as potential differences in social structures or mobility – are subject to ongoing investigation.

More Effective Response

An important possibility is that public health response of African countries, prepared by previous experiences (such as outbreaks or epidemics) was simply more effective in limiting transmission than in other parts of the world.

However, in Kenya it’s estimated that the epidemic actually peaked in July with around 40% of the population in urban areas having been infected. A similar picture is emerging in other countries. This implies that measures put in place had little effect on viral transmission per se, though it does raise the possibility that herd immunity is now playing a role in limiting further transmission.

At the same time there is another important possibility: the idea that viral load (the number of virus particles transmitted to a person) is a key determinant of severity. It has been suggestedthat masks reduce viral load and that their widespread wearing may limit the chances of developing severe disease. While WHO recommends mask wearing, uptake has been variable and has been lower in many European countries, compared with many parts of Africa.

So is Africa in the clear? Well, obviously not. There is still plenty of virus around and we do not know what may happen as the interaction between the virus and humans evolves.

However, one thing that does seem clear is that the secondary effects of the pandemic will be Africa’s real COVID-19 challenge. These stem from the severe interruptions of social and economic activities as well as the potentially devastating effects of reduced delivery of services which protect millions of people, including routine vaccination as well as malaria, TB and HIV control programmes.

Research Agendas

Major implications of the emerging picture include the need to re-evaluate African COVID-19 research agendas. While many of the priorities originally identified may still hold, their relative importance is likely to have changed. The key point is to deal with the problems as they are now rather than as they were imagined to be six months ago.

The same thing applies for public health policy. Of course, basic measures such as hand washing remain essential (regardless of COVID-19) and wearing masks should be continued while there is any level of COVID-19 transmission. However, other measures with broader effects on society, especially restrictions on educational and economic activity, should be under continuous review.

A key point now is to increase surveillance and ensure that flexible responses are driven by high quality real time data.

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  1. Nitpicker

    I point out that in advanced countries, people of color seem to be dying at a higher rate,

    I think you meant “richer countries”.

    1. Jerri-Lynn Scofield Post author

      Yes, I did. I saw your comment pending while it was in moderation and I immediately made the correction. Thanks for pointing out my mistake.

    2. Mixed Results

      The cluster of Vietnam, Cambodia, Laos and to a degree Thailand have a remarkably low incidence of Covid-19, despite very high levels of communication with China in the early stages, and highly variable levels of development of health services.

      This statement perhaps contains two ideas contrary to reality: it may be that these low rates are in part because of proximity to China (I’ll return to this), and it is worth at least noting that the rate of infection and death seems to be roughly inverse to the level of health care available. Cambodia, for instance, has bad healthcare (although good in multiple epidemiological areas thanks to polio, HIV, malaria, typhoid, cholera and other campaigns) and has not experienced any deaths at all, and the total number of cases is still less than 300, in a population of 16m.

      Vietnam has much better healthcare, thanks to its communist state infrastructure, and a very low rate of death and infection, but still lags behind Cambodia. And Laos is even worse for infrastructure of all kinds, but is doing exceptionally well. Thailand, on the other hand, has very good healthcare generally, and an enviable rate of death and infection to most other places, but is much worse off than the other 3 countries mentioned.

      The low death rate may well be a function of youth, and in the case of Cambodia, it’s worth remembering that a wholesale slaughter wiped out one quarter of the population in the late 1970’s. That means that there are a very low level of people over the age of 65 here. Vietnam had the the wholesale sustained slaughter by the Americans for ten years, as to a lesser degree did Laos and Cambodia; and all three had high levels of emigration after the war, draining that demographic section. So perhaps a combination of present young demographics, and the artificially-produced absence of people who are older is a factor. Africa is generally not doing as well as these four countries, but the youth factor is in common; what is lacking is the war, producing population loss, in that crucial period that corresponds to senior citizenry now.

      This makes me feel that genetic factors are very unlikely to be underlying benefits, but possibly (returning to the China proximity factor) a large population with strong exposure to a variety of transient coronaviruses, which is common in SE Asia, have produced an epigenetic ability to respond. The same may be true in Africa.

      While Asia is fairly genetically homogeneous, it’s a bit of a racist assumption that Africans are. There is enormous diversity there, as cursory reflection will show. But the predominance of dark skin as a consistent signifier of sameness plays an overblown role as a signifier for sameness in that shall we say Northern hemisphere mentality, so the proposals that Africans are beating the virus by genetic advantage are questionable. South America is genetically very variable, but is being slammed, as is the US. If African genetics were a factor, Brazil would be doing better than other countries on that contintent: not so.

    1. Jerri-Lynn Scofield Post author

      I don’t know much about Africa. But I know people make similar arguments about India. And I think in the age of social media, it’s much harder overlooking the untimely deaths of multiple grandmas. Maybe at the margins, but not enough to account for the state of the data.

      Yet I admit I simply don’t know.

      1. Thuto

        You beat me to responding to Synoia on this one. The thrust of my response to Vlade, still in moderation, makes pretty much the same point and I was going to refer Synoia to it in response to his assertion that it must be down to bad data that Africa has experienced a relatively low covid mortality rate.

        1. Synoia

          Covid is consider most infectious in enclosed dwellings. In in Africa there is much more outdoor activity, which coupled wither it being less deadly to younger people could result in milder and unreported infection.

          I don’t recall closing a window in Africa except the keep the a/c effective at night (In Nigeria) or on a cold winter night on the reef (Joberg and suburbs).

          It appears to me that the unfit, obese, with preexisting condition which prevails in much of the developed (average older) world could provide definite skew on the recording of Covid infections.

          Infant mortality rates are also higher in Africa than the West, and that could skew the surviving population to a more disease resistant average.

          1. troublemecca

            I believe the population to be far less mobile as well, due to fuel costs, etc. At the height of the pandemic in NY, I observed a much greater incidence of their distinct black and yellow license plates in FL.

          2. Mixed Results

            Why would death from a typical childhood cause impart immunity to a previously unseen virus? Surely not the “what does not kill me makes me stronger” argument, I hope. Virology is specific, not mythic…

            1. Jessica

              Higher childhood mortality might remove genetically more vulnerable children from the population and therefore also from any chance of getting Covid-19.
              Looking it at from the opposite angle, some of those who would have died from Covid-19 may have died earlier from some childhood malady.

    2. Thuto

      See my response to Vlade on this point, when it makes it out of moderation. With the unprecedented resources that were marshalled to stop what was being touted as a Malthusian disaster heading Africa’s way back in February and March, you’ll find that a lot of the data collection and reporting systems across the continent were primed to deal with this. Of course they’re not perfect, but show me a country that has.

    3. Abi

      This is not true today, if people were dying in Nigeria we would know.

      There may be no official records but we have things called social media, mobile phones and radio – news travels very fast and wide very quickly.

  2. PlutoniumKun

    A key difference, it should be pointed out, between dark skinned people living in the US and Europe and those in Africa is Vitamin D. I hate to bang the drum on this, but its been quite apparent from early on in the pandemic that there is a strong possibility of low Vit D levels being associated with mortality. And yet to my knowledge not a single major public health body has recommended supplementation, despite it being cheap and safe.

    Obviously, its too early to say anything definitively, but I suspect that along with the shameful overlooking of aerosols as a means of transmission, the role of heat and humidity in reducing viral loads in aerosol has not had enough attention. If this is the case, then its potentially very bad news for many Asian countries as winter hits, as even the success stories may find themselves with a new wave of infections.

    On the issue of exposure to other viruses giving immunity, its been recognised for centuries that childhood exposure to infectious diseases could give wider immunity to pandemics. Napoleon preferred sickly slum dwellers to strong country boys in his army, precisely because in his experience the latter were the first to fall when the inevitable wave of dysentry or other disease swept through an army on the march.

    1. vlade

      Not sure how it works in other countries, but I know that in the Czech Republic vit D supplement is made available for free for kids up to two years of age.

      Which of course doesn’t mean anything for seniors, but I do know that a lot of pharmacies are running out of vit D supplement here.

    2. Thuto

      Re: exposure to viruses giving immunity. I couldn’t agree more, we grew up at a time when parents didn’t oversupervise their children, and they certainly didn’t sanitize every surface kids come into contact with using the latest “kills 99.9% of germs” cleaning agent. I don’t remember any of my friends being as sickly as today’s kids, I mean hack one of our favourite activities was eating “Sphaphati”, which is Setswana (my native language) for improvised flatbread, a loaf of bread with fillings of chips, sausages, and other goodies. The “improvised” bit is where we wrapped the loaf in a bag, waited for an approaching bus (it had to be a bus as cars didn’t quite have the same effect) and let it literally drive over the bread. It was the most delicious treat, and none of us ever got sick from it. We even had a saying back then, “leswe ha le bolaye” which basically translates into dirt doesn’t kill. When parents weren’t watching and something spilled or fell of your plate, you’d simply wipe it off the floor with your mouth or pick up and gobble whatever it is that fell off.

      Some readers will probably cringe at these examples, and think them extreme, but this was our reality and it had nothing to do with poverty as we certainly didn’t grow up poor. What I know is that none of us were ever under the weather for too long, if at all. No parent in their right mind would allow this today, bombarded as they are by advertising that programs the fear of germs into them, yet this obsession with oversanitizing the play environment creates the sickly kids of today who are always down with one thing or another.

      With immunity, quantity begets quality, a developing immune system needs to encounter as many pathogens as possible to build out its defences and “enemy recognition capabilities”. If children are deprived of this during their formative years, as they are today, they become susceptible to all manner of infections in later life.

      PS: I’m not commenting specifically on covid outcomes, i’m speaking generally, and anecdotally about the seeming decline of immunity in kids and their susceptibility to various infections that weren’t much of a problem when we were growing up in the late 80s and 90s. My mother, a nurse with 50 years experience, confirms this “epidemic” of kids with weak immunity.

      1. CuriosityConcern

        Despite your mom’s vast experience and your own fond memories and experiences, I’m still thinking the arguments set forth are anecdotes. I don’t even disagree with you as I’ve heard healthcare practitioners talk about exposing their own children to dirt as a preventative.
        I saw your ps caveat and I realize you are not making specific claims about African mortality and COVID.
        Above, the good Reverend mentions vitamin D, my own COVID hobby horse is UV-C light and it’s effect on virus survival ex vivio. What are your thoughts on a combination of these things with an assumption of mine that at least in parts of Africa, people spend a significantly more amount of time out of doors than “first world” countries?

        1. Thuto

          You’re right, I think there is a lot to be said on the correlation between sun exposure, and hence vit D absorption by the body, and improved covid outcomes. The sad thing is not much is being said, but yes in Africa, people do spend a significant amount of time out in the sun and I myself try to do this for least 15 minutes on most days. So in agreement with you, I would posit that this, coupled with other factors like a young population, and the paucity of the “my rights come first/my body my choice not to wear a mask” types seen in America makes for a better outcome overall. While the “possible underreporting of deaths” caveat is often leaned on heavily in the media by confounded experts, what is undeniable is that the healthcare systems in most countries were never overrun, even in my own country South Africa, which as you know is the worst hit country on the continent.

          1. vlade

            I have a comment in moderation, but TBH, I’d not expect in any country that has a median age of 57 year old. If you’d naively (I hate this, as it’s wrong, but give some idea) move the median by 15 years towards 30 years age, the hospital system would not be overwhelmed.

            1. vlade

              Arrgh. Don’t know what happend to parts of the comment, so again.

              I’d not expect a country that has a median age of 27 years to have hospital crisis from Covid.

              The only place that was overrun (so far) was Lombardy. Median age in Lombardy is 45 years, and hospital admissions had IQR 57-79, so 75% of the hospitalised were >57 years old. If Lombardy had median age 30, its hospital system would not be overrun.

        2. Michael G

          There are two problems with UVC. Firstly, it damages DNA and will be carcinogenic. There is an argument that particular wavelengths (220nm) are blocked by other molecules in the skin and will not reach the DNA of your skin cells. Secondly, though, 220nm reacts with oxygen to produce ozone, which is damaging in its own right. I also worry that if the energy from 220nm UVC is absorbed, it will activate other reactive molecules in the skin, which will reach DNA. (I have no information whether or not this is the case.)

      2. PlutoniumKun

        I think you are absolutely right about this – I suffered a lot of ill health as a child from asthma – there is a high possibility that this was caused by an environment that was ‘too clean’, although my growing up was distinctly more organic and natural in that way than most kids now.

        I have a germaphobic friend who is obsessive about her childs cleanliness, and I genuinely worry that she’ll do more harm than good. I once jokingly told her I’d take her son out for a walk just to rub his face in some dirt – it didn’t go down well.

        Good to have you back commenting here, btw, your comments are always very welcome and interesting.

        1. Thuto

          Thank you for the kind words PK. I’ve been having a rather weird condition lately that’s kept me off computer and mobile screens for much of the last few weeks. While cleaning out my ear with an ear bud (I know bad idea) I accidentally poked the HQ of balance in the body, my inner ear. I’ve been suffering from dizziness ever since, and it tended to get worse whenever I tried looking at a screen (strangely enough not tv). Even the doctors were confused but thankfully i’m much better now and can take up one of my favourite activities again, reading NC and contributing where I can in the comments section.

          1. PlutoniumKun

            Glad you are better! I used to use ear buds until given a telling off by my doctor, she said she dealt with far too many cases of ear damage. She recommended just pouring in a little warm olive oil, and let it drain out naturally as the best approach to ear hygiene.

      3. The Rev Kev

        I can believe what you wrote, Thuto. Back in the American Civil War, troops that were recruited from dirty, disease-infested cities did relatively well on campaign but boys from country farms dropped like flies to diseases along the way.

      4. berit

        A European doctor on Manhatten around 1965 told me that Americans were so afraid of germs that all the washing and disinfecting made them more sick because of weakened immunity. Children being in contact with the natural world, soil, pets and other animals, were considered to aid in better resistance when my children later grew up on a small farm in northern Europe. Naturally strong immunity may be one among the many possible factors set forth in the interesting article. Thanks!

      5. lordkoos

        I don’t think it’s all about disinfectants although that it probably part of it. There are a lot more toxins in our environment now that kids are exposed to. Plastics leach gases which have hormonal impacts, furniture is full of flame retardants (mandated by law, even though toxic), there are a lot of insecticides and chemicals around too. Kids put plastic toys in their mouths and chew on them. It’s not surprising that food allergies which were once rare are now common, many kids and adults have developed them in the last 40 years or so.

    3. juneau

      Please keep beating the drum. The international data showing a negative correlation between Covid severity and vitamin D level is consistent and strong (I understand correlation does not equal causation but there is evidence for this with flu severity too). My friends from eastern Europe who got BCG are all well despite taking risks with this virus (anecdote). Malaria/Covid prophylaxis with the 3 unmentionable antibiotics may play a role in the southern hemisphere. My main sources on this are medical bloggers Dr Been and Dr Campbell. Dr. Been is an academic immunologist and Dr Campbell is a PhD nurse who has done 3rd world medicine and is a medical educator that some here may know of….. No doubt having a lot of skin exposed to the sun could help. US providers have their hands tied by regulation, don’t want to kill anyone with the wrong advice, but even the local docs are recommending Vit D near me. Look at what was given to Trump and you get a good idea of what has been studied and shown to be somewhat helpful (except maybe for the antibodies which were a big experiment).

    4. Stillfeelinthebern

      Milk is Vitamin D fortified in the United States and Canada. What role does this play?

      1. Reality Bites

        My understanding of fortification is that very little is ultimately absorbed by the body. It is the same with many boxed cereals. Therefore the effect is minimal.

      2. PlutoniumKun

        I don’t know the levels in US milk, but I suspect they are far too low – people in the northern hemisphere have levels far lower than seems natural for humans. And there are issues with bioavailability – some people take a lot of supplementation while still having low levels (I don’t know the reason for this). There is little substitute for the most natural way of all to get it – have a stroll in the open air at lunchtime, especially in winter.

      3. Louis Fyne

        liquid and processed milk consumption per capita in the US (dunno about CAN) has been declining for decades.

        If I recall correctly, we’re at an all-time low or near all-time low. See small dairy farm bankruptcies all around the US

    5. Patrick

      Fauci advocated taking vitamin D. Well…perhaps advocated is to strong a word. He said you should “avoid taking immune boosting supplements” which he considers fot the most part useless, and embrace vitamin D instead. He takes it himself. So he offers a sort of vacillating recommendation, or one with a disclaimer, “do this because I do, but heaven forbid you should do anything else because it’s useless”. That’s not a direct quote, it’s my interpretation of what he’s saying. You can find numerous studies online that completely and vehemently repudiate the benefits of every single vitamin, every herb, every supplement and every approach to health, healing and disease treatment other than the orthodox western one. Mostly from what are considered reputable sources, such as academic and medical institutions and agencies that ran studies funded by big pharma. You can find studies that are a little bit more tolerant, but they never stray far too from the primary, established western orthodoxy, and much of the time the information they share is incomplete or flawed, giving me the impression that they are either incompetent or serve the purpose of gatekeepers. You have to dig deeper to find the studies they did in China treating covid 19 with intravenous vitamin C, and to discover it’s history of success in treating a number of other very serious health conditions. In doing so you’ll find that there is a form of vitamin C that can be taken orally that approaches the potency of the IV administration of vitamin C in terms of blood levels and bioavailability. You won’t hear anything about the homeopathic formula that was developed in Cuba specifically for the treatment of covid 19, which is available to the population free of charge. There’s an article from September 20th on the BBC website about how the WHO is setting rules for testing African herbal remedies for covid 19, but no mention in this NC article about it’s existence or the possibility of it being a determining factor in their lower mortality rate. That isn’t meant to be a criticism. It does however raise the question of India and Ayurvedic medicine as a potential area of research. It would after all be part of what is considered different in terms of specific or unique regional behaviour. In my opinion, for all intents and purposes the approach being taken to the pandemic right now is one of herd immunity, although it would never be spoken aloud or admitted to. The energy and focus seem to be primarily directed towards managing people’s expectations, with a decidedly downward trajectory. Studies have shown that an oil based or micro encapsulated form of Vitamin D3 is the most efficacious supplemental form. If you are taking matters into your own hands remember this; “First, do no harm” It seems to have been forgotten or cast aside by those whose sacred duty it was to uphold it.

  3. vlade

    The only good indicator of deaths is IMO excess deaths indicator, for a large variety of reasons (people may day not directly because of CV, but because they could not get other care. Other people, who might have died of flu will not, because flu spread was dramatically lower than normally. etc. etc..).

    I have very much doubts that most African countries, or India, have good excess death statistics, given that in a number of cases they do not have even good census statistics. The post uses Kenya, but I do not have any idea how good Keyna’s data actually are, and it’s not clear from the post either.

    Russia, for example, was being given as a good example of “many cases, few deaths”. Except that excess deaths are running very high, and even by Rosstat (Russia national statistical beauro) own numbers, which have a significant lag, Russia deaths “linked to CV” are about three times what the official government numbers are (for August, Rosstat has “CV deaths” at 26k, “linked to CV” at 45k, while the official govt statistics say 17k. Go figure.).

    In the absence of quality data, the speculations are meaningless, so the first step the authors should have taken is confirm the quality of the data.

    1. Thuto

      I think you’re confounded, and like most people who are, you reflexively lean on the “questionable data integrity” caveat, which is to say you’re also dabbling in speculation. I don’t think any statistics anywhere can be relied upon to be highly accurate. Sure some countries will leverage better data collection and reporting systems, but I doubt the low mortality rate across 55 countries and a billion people could be mainly down to poorly reported data. Some covid deaths will surely slip through the cracks, but this is true everywhere. The important marker for me is that the predicted buckling of African healthcare systems under the weight of covid didn’t happen, and that Africa generally has leveraged its accumulated wisdom gained from encounters with other epidemics to position itself to deal with this one better than it would otherwise have, which it is doing so far.

      1. vlade

        Sorry, but if the model predicts 4k missing deaths in Kenya, it’s almost a statistical error for the size of the country.

        I do extrapolate from one African country (Ethiopia) I had to deal with a government and data, and some other African governments I was exposed to (Zambia, Ghana) , so while I can’t claim to be super knowledgable, I do have some datapoints on data quality in Africa.

        A company I founded was looking at a tender by Etiopia’s govt to fix their data collection and aggregation in agriculture. It was an unholy mess, and I suspect the only reason the govt was tendering was to have somene to blame when it all failed. We said “no thank you very much” very very quickly once we dug a bit deeper.

        And I’m not coming with “it’s the 3rd world Africans” stuff – often it’s not just the system, but the governments are facing problems that are much different than in Europe, especially when it comes to data collection from rural or poor areas, when even if data is collected, it can be easily months old by the time it is sent. We have also dealt with some SE Asian countries, and while in general they have better abilities, if they have very rural and isolated regions, they don’t fare much better, and I have my doubts whether anyone could.

        Given that for example African climatological, demographical (young population) and immunological (I doubt that SE Asia has less infectious diseases than Africa exposing population to various pathogens) parameters are replicated elsewhere, Occam’s razor at the moment suggests that the problem is in the data – until proven otherwise. I.e. it’s not impossible that Africa _is_ special. But to show that, you need to provide IMO much better data than currently available.

        South Africa has probably the best data collection on the continent, and the South African mortality is three times higher than European Czechs, who have, so far, the worst second-wave in the Europe case-wise (18.5 out of 700k, 2.6% vs 1.5 vs 180k, 0.8%). It is better than average European mortality (250k out of 7.47m cases or about 3.3%), but that is not age-adjusted. SA ha median age of about 28, vs European 42, so in other words, looking at South Africa, there’s no real unexpected variation.

        On the buckling of the health system – the health system in the EU is swamped _mostly_ by over 50s. I don’t mean there aren’t younger patients – but a very substantial majority of severe hospitalisation are >50 of age. If your median age is <30, it's unlikely that you'll swamp your hospitals.

      2. Thuto

        From my perspective, the “missing 4kdeaths” is a misleading statistic to use as a basis to anchor your argument because as pointed out further down in the comments, the factors that influence the varying outcomes seen in different countries are many and will take years to be combed through. As such, applying one overarching standard model to all countries and tweaking it to adjust for variability of individual input data points is misleading when no one has the full picture of what’s truly driving the differing outcomes we are seeing. In other words, the models may be missing far too many key inputs for them to be used as anything other than guideposts I.e. directionally useful but not to be used in isolation to drive key decisions. I think governments are waking up to this

        Also, i’m not sure when your encounters with the tender happened, but I do know that the data collection and reporting systems around covid specifically were massively primed in most countries across the continent to prepare for what was said to be an approaching Malthusian disaster. No politician wanted their populations wiped out on their watch (or their conscience), so a lot of preparatory work around systems readiness was undertaken. As such, I think it may be a tad misleading to look at the present through the prism of your past experiences in this regard.

        1. vlade

          “we would expect around 5,000 deaths. There is still a big difference between 700 and 5,000; what might account for the remaining gap?”

          The “missing 4k” is not my argument, it’s the premise of the post which then goes and tries to explain the gap.

          I agree it’s misleading statistics to anchor the argument – which is my point that the 4k is less than a statistical error. Trying to explain it by some African exceptionality is IMO wrong, as any such argument would need to be very strong, on much better numbers. Exactly beause the reasons you say – there is tons of other reasons the models may be missing, and usually “exceptionality” tends to be explaining factor only if the researchers want it to.

          The tender encounter with Etiopia is about two years old. I cannot comment on covid data collection (although it’s not a covid data collection, its the quality of census data, specifically death registrations), but the problems I saw there were systemic (on both the reporter and receiver sides), and I do not believe they could be fixed in two years.

  4. The Rev Kev

    Another possibility which I have mentioned before in a previous comment is that Africa has always been prone to malaria. And of course a mainstay of medication for malaria is hydroxychloroquine which has been in use for about seventy years and is cheap as chips. Hundreds of millions of doses have been administered in all that time. Add to that the fact that a survey of this drug just before the pandemic arrived found that there has never been a death directly contributable to its usage and what is not to like.

    I think it likely that it was used in the early treatment of Coronavirus in Africa and other regions and this is reflected in the death rates mentioned. A coupla months ago I saw a chart that showed that countries which used this drug experienced lower death rates whereas countries – usually more advanced – which listened to their pharmaceutical corporations for advice and banned usage of this drug experienced higher death rates. of course what is needed is a study to prove this one way or another but we all know that this will never be allowed in the present atmosphere.

    Not a fanboy of this drug one way or another and not sure if if works well but as I always say, it would be nice to know.

    1. Jerri-Lynn Scofield Post author

      Same applies to India re malaria and if IIRC, the government is supplying health care workers with HCQ (or did I mistakenly remember that. It’s been a long day and I am about to sign off for the day so apologies as I am too tired to look it up.)

      1. The Rev Kev

        Jerri-Lynn Scofield
        October 20, 2020 at 12:34 pm

        You remembered correctly. I saw that in a Peak Prosperity video months ago so probably India re-dedicated their stocks to fighting this virus by protecting those health care workers. I seem to remember at the time that some big organizations were unhappy about this development but had nothing else to offer India in its place.

    2. Abi

      Sorry excuse me, but what do you mean Africa has always been prone to malaria? I have never had malaria in my life and I am 100% African living in Africa, in fact many Africans do not even get malaria to begin with, so no we are not all just pumping hydroxychloroquine into our systems, ever heard of allergies? So many of us are even allergic to the stuff, the same way people are allergic to penicillin.

      Please do some research and stop regurgitating incorrect assumptions.

  5. Synoia

    I’d expect inaccurate statistics from Africa. I doubt the accuracy of their birth and death records, and in many cases expect them non-existent..

  6. Grumpy Engineer

    @PlutoniumKun: You said, “It’s been quite apparent from early on in the pandemic that there is a strong possibility of low Vit D levels being associated with mortality. And yet to my knowledge not a single major public health body has recommended supplementation, despite it being cheap and safe.

    Aye. And how about recommendations for Vitamin D testing, to see who’s actually deficient? And recommendations for air filtration to reduce the propagation of droplet/aerosol-borne virus particles in indoor environments? These seem like “no-brainers” to me, and yet we’ve gotten sidetracked into arguments about masks.

    1. Abi

      To be fair, the people who had covid here in Nigeria were usually put in well ventilated tents outside and their treatment included vitamin D, Zinc and Vitamin C.

      While most recovered, the people who died were older and had underlying conditions

  7. flora

    Dr. John Campbell has a recent video where he examines C19 infection rates and death rates in general, and in various countries.

    He points out correlations between age groups of infected and death rates from C19. The under 50 age group has a very low death rate from covid, and the over 70 has a much higher death rate than the under 50 group. He then looks at countries’ age demographics. Interestingly, countries like Niger, Kenya, and many African countries have many fewer people who live into old age from all causes. So there are simply fewer percentages of the over 70 group in many African countries, the age cohort that has a higher fatality rate than the under 50 group. So their statistics from C19 fatalities look better than countries with higher percentages of over 70.
    It’s an interesting correlation. (The theory doesn’t explain Japan’s better outcomes. Other factors? More vit. D from a high fish diet?)

    full video:

    the bit of video discussion national demographic pyramids.

    1. PlutoniumKun

      I haven’t had time the past few months to keep up with Dr. Campbell, but he is definitely one of the most level headed commentators so I’d listen carefully to anything he has to say.

      But yes, I do think that the relatively low figures in Africa might be at least partly connected to a simple matter of age demographics. But having said that, I don’t see any evidence that health systems in Africa (and yes, quite a few African countries have pretty decent health systems) are overwhelmed in any way.

      Japan is an interesting case. Even my Japanese friends seem puzzled by how the country has gotten away so lightly, when the government was so inept and dishonest at the beginning. I can’t recall the source, but one article I read attributed to local health authorities being far more efficient at identifying possible super spreader sources and nipping outbreaks in the bud. This could be the reason why a fairly steady background level of Covid hasn’t gone exponential. But yes, its also possible that the diet (not just fish, natto and other Japanese foods are associated with strong immune systems) may have helped. Its also worth pointing out that in comparison to most cultures, the Japanese are really not into big public gatherings and being noisy at them, and not really into casual chit chat either (although it should be said that typical Japanese bars are pretty intimate and unhygienic).

      But I think the Japanese government is quite worried about the winter, and cold weather pushing people into closer proximity, especially the old folks (older people in Japan are strikingly active and outdoors oriented, they always seem to be out and about making themselves busy). They are currently trying to persuade more people to work from home, something that the average salaryman is very reluctant to do, as that might mean they’ll have to talk to their wives.

  8. DSB

    Right after the relative youth of the populations of the areas mentioned in the article and comments, was in my mind obesity. The CDC cites it as a risk factor for severity of C-19. If you look at the CIA’s World Factbook, the first African country I see is Botswana at 114th in the world. Kenya, mentioned in the article, is number 161, while India is number 189. Mentioned in the comments is Japan, which comes in at number 186. It may not be the weight so much as the positive contributions that make up lower body mass index.

    Correlation is not causation, as mentioned previously.

    1. PlutoniumKun

      Yes, thats another point when it comes to mortality. My niece is a hospital doctor, and she said that she quickly learned that she only needed one metric when assessing incoming cases to know if they will likely require IC – whether they were obese or not.

    2. Basil Pesto

      no it isn’t, and I think the simple fact is given the planetary nature of the virus, there are so many (I mean, truly SO many) variables at play from region to region that figuring out precisely what makes the virus more damaging in some places rather than others (not just between countries but within countries, too) could take many, many years to figure out with anything approaching certainty. It makes for a somewhat fascinating public health puzzle, though.

      1. workingclasshero

        Obesity and type 2 diabetes have always contributed signficantly to negative health outcomes for people across the disease spectrum,especially covid 19.don’t really have to overthink this thing basil.

        1. Basil Pesto

          of course, but again, there remains an enormous number of variables that stack with that one, including:

          – genetic factors
          – vitamin D intake
          – mask wear and fit
          – architecture (air circulation)
          – viral load
          – weather/climate
          – treatment
          – age

          etc. & so on

  9. David

    From the time I first set foot in Africa nearly thirty years ago, Africans have been taking me by the arm and saying “don’t forget, Africa is the most diverse continent in the world.” From my (admittedly incomplete) experience, that’s absolutely the case, and all generalisations about the continent are dangerous. The article only quotes the example of Kenya, and I really wonder how valuable that is in isolation. I would actually turn the argument around: it’s not that Africa is “different”, but rather that Africa is so vast and varied that a more granular set of figures might show some interesting differences.

    I mean, Africa is hot? OK, but German tourists go down with pneumonia after turning up in T-shirts and shorts to see the gorillas in Rwanda. It’s chilly in winter in Namibia, or parts of Ethiopia. I’ve seen frost on the ground in the morning plenty of times in Joburg. Africa is sunny? Relatively, yes, but in Kinshasa you can have cloud cover lasting for days, and along the coast of West Africa in the rainy season, the sun only comes out briefly. And so on. I think the point about relative youth is important, I think the point about (relative) exposure to sun is important – in every African country I’ve been in, people spend a lot of time in the open. And I think Thuto’s point about immunity is well taken. I don’t think it’s just under-reporting either. In fact, until we have more detailed figures properly analysed by experts, I’m not sure there’s much we can say for certain.

    Thuto (glad to have you back) from what I hear, SA has been relatively hard hit. Given that it’s the most developed state on the continent, what do you think the situation there tells us?

    1. John Rose

      The genetic variation in Africa is most striking of all. The genomes of all non-Africans correspond to the genomes of few African populations. That means that the human dispersion out of Africa involved only those populations. That left Africa with a genetic variability vastly greater than anyplace elsewhere in the world.

    2. Thuto

      Thanks David, yes we are the worst hit country on the continent and this is tied directly to being the most developed nation. The worst hit provinces tend to be the ones with the most economic activity, and hence the most connectivity to the outside world. I guess when benchmarked against other countries this comes as no surprise. We’ve seen a major drop off in the infection rate since the peak in August, even with the lockdown easing to its lowest risk level. Most of the dire predictions haven’t come true yet, here and across the continent and I tend to think this has a lot to do with Africa harvesting its demographic dividend re: age distribution.

  10. Calypso Facto

    I had an ex with a sister who married into a large Ghanian Hausa family, and in 2011 we went to Accra for a month for the wedding. While there, I contracted a short mystery illness – we assumed from the water – and then about 6 months after my return to the states I developed a severe pneumonial illness that nearly killed me. Again, no clear cause, no real options other than to rest and wait out the acute phase (which lasted almost 2 months) and hope for recovery. Afterwards I experienced body pain and inflammation issues that correlated with hormonal changes for years, gradually decreasing in severity until I could predict which days would be ‘pain days’ from this bizarre nerve/musculoskeletal pain that felt like feedback rather than direct pain, if that makes sense. Like my pain receptors were subjected to something that made them think they were sensing pain but they were not. The only thing that helped was slow stretching, baths and resting. The doctors never figured out what either illness was or was caused by, and could offer me no real help for treatment (without me risking financial ruination for what ultimately came down to rest, light exercise, and stress reduction).

    I share all of this for three points:

    – The above piece made me think immediately of being sick in Accra and being shut away in my air-con guestroom while everyone else was outside, in the sun, in fully-ventilated and partially-open structures, which there at least they can do year-round. I believe that is also the case in much of India, where virus cases are lower than expected – more time spent outdoors rather than in un-ventilated, air-con structures.
    – My experience with the mystery illness I contracted in Ghana in 2011 as well as much of the discussion here and among researchers about the role of stress and hormonal signal disruption makes me wonder how much of Covid 19 recovery rates are dependent on whether the body can harness its own immunosuppressive powers to recover in time given a certain viral load. And if that hormonal signalling system is out of whack, as in those who are obese or elderly or very stressed out, perhaps this results in worse outcomes. A question like ‘are Africans less stressed than North Americans?’ is vacuous bordering on futile however and I am unsure how to make the question more specific and relevant. But I do suspect the stress and obesity levels are higher in areas with worse outcomes from Covid 19.
    – Thuto and PK make points above about over-sanitization and exposure that I think are very relevant as well. I’m not sure all of the blame can be placed on helicopter parents, some must be reserved for the sterile and dead soil conditions in areas thick with monoculture and pesticided grass… very prevalent in the USA, where the outcomes are the worst in the world.

    1. Lambert Strether

      > some must be reserved for the sterile and dead soil conditions in areas thick with monoculture and pesticided grass

      Interesting connection, “dead soil” and the immune system. Glyphosate, for example. And I’m sorry you got this disease, whatever it is.

    2. Abi

      Sounds like you had typhoid fever, it’s very common here but can very quickly turn into pneumonia. I suffered the same when I was about 8 nearly died, but I survived, unfortunately my brother died from it.

  11. H

    There is also another drug even older than HCQ:
    artemisia annua:
    Make tea or simmer down to 5x, 10x strength & bottle it. In Africa they drink gallons for malaria.

    UK growing tons for research:
    Hope is it’s derivatives will ease symptoms enough to make Covid more survivable.
    Helps hemoglobin carry oxygen among other things.
    Very bitter & more likely to want a nap.

    1st derivative available w/o prescription: Artemisinin:

    1. H

      Re: Artemisia
      Have seen it growing along fencelines near 1800s farmhouses. It was once a lifesaver.
      I have a great-great grandmother named Artemisia.

  12. John T

    In my view, Ms. Scofield has missed the elephant in the room as to the lower fatality rates for covid-19 in Africa compared to people of African descent living in the west. Vitamin D levels.

    * A randomised control study in The Journal of Steroid Biochemistry and Molecular Biology August 29, 2020, Hospitalized COVID-19 patients given supplemental calcifediol (a vitamin D3 analog) in addition to standard of care lowered ICU admissions from 50% to 2% — and eliminated deaths

    * Another study published online September 25, 2020, in PLOS ONE, found COVID-19 patients with a vitamin D level of at least 30 ng/mL had a significantly lower risk of adverse clinical outcomes, including a 51% lower risk of dying

    * Based on data from 191,779 American patients, people with a vitamin D level of at least 55 ng/mL (138 nmol/L) had a 47% lower SARS-CoV-2 positivity rate compared to those with a level below 20 ng/mL (50 nmol/L)

    Experts such as Dr. Michael Holick, a professor of medicine, physiology and biophysics and molecular medicine at Boston University School of Medicine (also a GrassrootsHealth’s vitamin D panel expert and widely recognized as one of the leading vitamin D experts in the world), along with Rufus Greenbaum, a citizen scientist in the U.K., physicist Gareth Davies, Ph.D., and Drs. William Grant and David Grimes made a presentation highlighlighting the benefit of vitamin D to covid-19 patients, one of the key quotes was made by Dr. Grimes which sums up vitamin D’s importance.

    “The evidence for vitamin D is overwhelming. During a pandemic, all people should take a vitamin D supplement.”

  13. Abi

    All these speculations. You know you could have just asked Africans ourselves and we would tell you. From Nigeria’s perspective I can tell you how it went. Covid came on flights from UK and the US, and maybe except a few flights escaping all were quarantined and contact traced. Immediately my state (Lagos) went into lockdown in early April because we are the largest airport hub, domestic flights and travel were also banned except essential travel. All our potential large gatherings – church, mosque, schools and bars/restaurants/parties were locked down till just a few weeks ago. From April till the end of August, pretty much no one went anywhere. And kids have not really returned to schools either, parties and church/mosque service attendance is still very low. That aside, we have mainly open air markets, so even when you have to mix outside its out in the open. It wasn’t rocket science, people got it and they recovered while a few died. We just managed it well, maybe because we were on alert due to ebola, but naija no dey carry last.

  14. Fritzi

    A catastrophy that for once harms the global south less than the global north?

    Perhaps there is something like karma after all.

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