An Taoiseach Leo Varadkar has indicated that he no longer thinks that Ireland will reach the 15,000 cases of Covid-19 virus infections by the end of March. Now two weeks since the first restrictions were announced in Ireland and with further stricter restrictions announced, without risking accusations of complacency, it appears that Ireland Inc. has done well so far to avoid a spiralling situation such as occurred in Italy and Spain. Caseloads have been reasonably stable at 200 per day, cognisant of backlog in testing and test results. It has not been calamitous so far.
For certain, much of Europe should recognise their good fortune in having had the forewarning from how the situation evolved in Italy which has allowed them to take more proactive mitigation measures, while Italy itself was exposed to the coronavirus without the same level of forewarning. Indeed, the loss of many lives in Italy has, in some way, meant lives have been saved across the rest of Europe, and possibly the world.
That said, as Europe has become the epicentre of the pandemic, and many eyes now fall on the United States, there is another part of the world that has remained off the radar. If we feel that the coronavirus has been a major disruptor to life in Ireland, it is likely that the situation across Africa may put that in perspective. While we have been (rightly) consumed with managing and minimising the impact here in Ireland, coronavirus has begun to spread across the continent of Africa.
As of writing, Ireland has 1,329 cases and the country has been in many ways turned upside down. Our health service is under severe pressure, our social lives have been put on hold, many elderly are feeling isolated and alone and hundreds of thousands are currently out of a job. Ireland has the resources, and the credit rating, to bolster its health system and offer economic security to businesses and individuals as we face into a long spring and summer.
But of countries in Africa, South Africa has the largest caseload with 709, Egypt next with 442, followed by Algeria, Tunisia and Morocco with less than 200. These are the wealthiest African countries, with reasonable systems in place for identification and testing but they have neither the structures or resources of European countries to either identify or treat. Further down the line, the Burkina Faso, Senegal, Ghana and Nigeria are around 100, with places like Cameroon, Ethiopia, Sierra Leone having cases between 1 and 40. South Sudan is the only country with no cases at all.
But those figures mean very little. Where there are any cases at all, there are undoubtedly more – probably many more. In countries where there are barely functioning governments, never mind health systems that can deal with a pandemic, the true extent of situation across the continent will never really be known. Many of these countries struggle with other communicable diseases- in 2016, 718,000 people died from HIV/AIDs related illnesses, 660,000 from diarrheal illnesses, and over 400,000 from each of malaria and tuberculosis. The highest cause of death is respiratory tract infections with over 900,000 deaths each year. Very little is known about the numbers who die from flu type illnesses. All of these in Europe are preventable deaths.
But Covid-19 is already starting to shut-down the continent. Governments know that they have to act fast to have any chance. Relying on health infrastructure for treatment will be futile. Even with unlimited investment, the infrastructure will not be there quick enough, nor the health personnel in place to deal with it. The systems will not be in place to do testing, even if the governments can find the resources to procure the testing kits in an already competitive sellers’ market where developed countries are struggling with almost blank cheques.
But how will containment work? In Ireland, social distancing is manageable where the infrastructure is in place to work from home, where supermarkets are spacious and accessible, where an average of four people live in a house, and often fewer, and online buying and cashless payments are an everyday occurrence. Loved ones can talk to each other over skype, whatsapp and facetime and hours can be passed with endless series on Netflix or Amazon Prime. For those that are not in work, the government can borrow, and be confident of repaying, the loans to finance subsiding salaries and providing even more generous welfare payments than usual. In terms of hygiene, though in short supply, hand sanitizer can be found and is affordable, running water and soap is plentiful and available.
All this is a dream in much of Africa. Governments are already in debt and borrowing at much higher interest rates that Ireland does, with low credit ratings. There is no chance of social protection for the vast number that work in the informal economy. GPs, never mind ICUs, are often only accessible only to the privileged few. Often the only healthcare that is available are rapidly trained community health workers, operating from a bike and travelling very far by road. Personal protective equipment will be hard found.
And what of the health and hygiene? Hand sanitiser can cost more than a weekly salary. Running water out of a tap in your house? Think again – often it is a long queue at a well, dropping a bucket down a hole or pumping at a handpump in the midday sun with a long walk home afterwards. Social distancing in rural areas can be manageable in good weather but the norm is large families in small houses. In urban areas, the population density in slum areas, some of them built on the worst possible land without sanitation systems, is unimaginable.
A two-bed apartment would house ten or more people, extended families. Social distancing? Just not possible. Imagine Cairo with a population of 19.5 million people. If the option is to stay at home or go to work, it is often a decision about survival. For many, such as the informal trader in the busy urban market at the edge of a city, the choice of not going to work – working for yourself – is a decision to go without food for the day. An impossible choice. And what of getting to work? You don’t have your own car. You can’t afford to take a taxi all to yourself. You get the local minibus, always packed with anything up to 30 people in a Hi Ace.
Any case of coronavirus will spread like wildfire across busy markets, buses and overcrowded houses. Handwashing, difficult in itself, would be almost futile in any case. And what happens when you get infected? You deal with it yourself. There will not be Intensive Care Units to go to. There will not be ventilators except in rare cases.
And then there are other complications. Burkina Faso has about 40 known cases. It is in the middle of a jihadi war where over 600,000 people have been forced from their homes. Some are piled in on top of relatives in safer places. Most are in rapidly set up settlements, with little access to water and no infrastructure. In Cameroon, there is a nascent civil war going on where the English speaking regions are uprising against the French speaking government. In the Anglophone areas there is no government presence.
There are places like South Sudan and the Central African Republic that are riven by conflict for years and basic services are absent. People live in a constant fear of fighting. Many of these countries are dependent on foreign aid to keep the basic services running. With the coronavirus about to force a near global recession or possibly a depression, this vital lifeline will be diminished as governments in the wealthier countries are forced to tighten their belts and also pay the costs of the welfare supplements that are being put in place.
Urban slum areas and informal displacement camps provide the most dangerous of scenarios: high population density, crowded houses, no water or sanitation, poor disease surveillance, and rudimentary health services.
Of course it is not just Africa – it is Yemen, Syria, Myanmar, Bangladesh, Afghanistan, Gaza in a world with more than 25 million refugees and over 40 million forcibly moved from their homes by conflict within their own countries. If the virus manages to get a foothold, as it probably already has, the predictions of millions of deaths from this virus will come to pass. But it won’t be in China, or the US or Europe, but in the poorest places across the world. And the NGOs that work in these places will have less funds to do so but also not be able to do their work
“Many humanitarian operations are scaling back physical presence, recommending their international staff return home and closing offices,” according to a March 19 report by the Assessment Capacities Project, a Norwegian nonprofit that provides analysis of major humanitarian crises. “Ongoing restriction of travel, suspension and changes to scheduled flights is likely to continue to disrupt humanitarian operations.”
A report from Crisis Group, highlights how the Rohingya in Bangladesh could be affected: “Also of concern are the Rohingya refugee camps in Bangladesh, where over one million people live in overcrowded conditions, with sanitation facilities and health care services limited to a bare minimum. A government ban on internet and mobile phone services in the camps limits access to vital preventive information, while high levels of malnutrition likely imply that both the refugees and local residents are more susceptible to the disease. Should COVID-19 reach the camps, humanitarian agencies expect it to spread like wildfire, potentially triggering a backlash from Bangladeshis who live in the surrounding areas and are already unnerved by the refugees’ prolonged stay.”
The only bright spot is a cruelly ironic one. The coronavirus is most lethal for those in the 70s and older. The average life expectancy in West Africa is 57 years but as low as 50 in the Central African Republic. In Africa, the vast majority of people in Africa are already dead by the time they reach the age of greatest vulnerability. Although little remains known about how the virus will impact in countries of much lower life expectancy, and with poorer health indicators than in Europe, this grim irony provides only a dull silver lining. With the prevalence of other immune depleting illnesses, poor nutrition and underlying health issues that cannot get treated, the fatailities will likely occur and be many. We may never know, though, exactly how many, as most will never be tested.
Dualta Roughneen is a humanitarian aid worker and was in Sierra Leone responding to the ebola outbreak