A COVID-19 Commission of Inquiry can improve pandemic preparedness in Africa
Ann Ithibu and Alan WhitesideArticle Type:
Article Number: 3
The Commission can improve early detection of outbreaks to curb the spread
ABSTRACT The Global Fund has called for an African commission to investigate the COVID-19 pandemic in Africa. We urge the African Union or a similar body to establish the ‘Commission on the Origins and Spread of COVID-19 in Africa’ to examine the continent’s preparedness to detect the outbreak and virus variants. The Commission can also help explain why Africa has, so far, reported a modest number of COVID-19 cases compared to its counterparts, and why some countries in the region were more affected than others. The findings of the Commission of Inquiry can then be used to inform preparedness for future pandemics and other public health emergencies.
The Global Fund Observer has called for an African commission to be established to look into the COVID-19 pandemic in Africa. We urge the African Union or a similar body to establish the ‘Commission on the Origins and Spread of COVID-19 in Africa’.
A commission in governance terms is defined as a formally chosen group of people who have been appointed to discover information about a problem or examine the reasons why the problem exists. In the health field, the premier medical journal The Lancet has been using this route to examine a wide range of issues. Its website says “Through our programme of Commissions, The Lancet editors work with academic partners to identify the most pressing issues in science, medicine, and global health, with the aim of providing recommendations that change health policy or improve practice.” (https://www.thelancet.com/lancet/commissions). So far six Lancet commissions have reported in 2021, the most recent on 24 October ‘Governing health futures 2030: growing up in a digital world’, which was in collaboration with the Financial Times.
Calls for these kinds of non-partisan commissions are becoming increasingly common – only this week, two Canadian newspapers called for a non-partisan commission, asserting that this is what Canada needs to address the emerging national challenges presented by climate change.’
The Commission on HIV/AIDS in Africa ran from 2003 to 2008. It was led by KY Amoako, head of the United Nations Economic Commission for Africa, headquartered in Addis Ababa. It was ‘charged with analysing the HIV/AIDS pandemic’s implication for governance in Africa and making recommendations based on the analysis’. The Commission operated by commissioning specific studies and holding hearings, at which governments, donors and, importantly, civil society were invited to make submissions. Hearings were held in Botswana, Cameroon, Ethiopia, Ghana, Morocco, and Mozambique. The report is available at http://dag.un.org/handle/11176/89804
I (Whiteside) was one of the commissioners, and it is this experience, along with The Lancet’s use of this route, that means we see the value of the Commission on the Origins and Spread of COVID-19. It is particularly important to address the ‘fake facts’ and misinformation that have been spread about the pandemic. Misinformation, particularly around how COVID-19 spreads, was a barrier to reducing the virus infection rates. This challenge is reminiscent of Ebola in the recent past, and before that, HIV. The right group of eminent persons, the majority African, will be able to send clear messages to audiences that are being fed misinformation. The Commission can also highlight the cost of misinformation on curbing the spread of the virus in Africa and determine good practices in addressing it.
Spread of COVID-19 in Africa
The Commission should examine the spread of the virus in sub-Saharan Africa. The virus spread to countries with variable epidemiological patterns since the first case in Nigeria in February 2020. Existing literature already elaborates the chronology of the pandemic since its emergence In Wuhan, China, and its spread to North America and Europe. In contrast, little is known about how the virus spread once the disease reached Africa.
The Commission could help clarify the actual burden of the disease in Africa. By 20 November 2021, the continent had reported 8.58 million COVID-19 cases (compared to 81 million in Asia, 71 million in Europe, 57 million in North America, and 39 million in South America). Some people have argued, with good reason, that low testing rates have underestimated the number of COVID-19 cases reported in the region. Indeed, most African countries have reported fewer tests than the rest of the world (Table 1). But suppose the actual burden is lower than the rest of the world. In that case, the Commission could attempt to explain why, in light of Africa’s fragile health systems, urbanization, and a large immunocompromised population due to disease or malnutrition.
Table 1: A comparison of total tests per thousand between top-four high burden countries in sub-Saharan Africa vs. the rest of the world
|Country||Total tests per thousand||Country||Total tests per thousand|
|South Africa||316.99||United States||1942.51|
Various publications have attributed the lower burden in Africa to the younger populace, prior exposure to other coronaviruses, countries’ experience in addressing infectious diseases (such as Ebola, HIV, malaria, and tuberculosis), good community health systems, the low burden of non-communicable diseases, and favourable tropical climate. In addition, most countries quickly introduced public health measures, including avoiding handshakes, frequent handwashing, social distancing, and wearing face masks. The Commission can examine to what extent these measures helped curb the spread of the virus.
The Commission should also explore why the pandemic has affected the continent disproportionately. For instance, South Africa has recorded a record number of cases – 2.93 million COVID-19 cases by 20 November 2021, accounting for 34% of the continent’s total number of cases – in contrast to the rest of sub-Saharan Africa. In comparison, Ethiopia, which has the second-largest burden of the disease in sub-Saharan Africa, had only recorded 370,200 cases by 20 November 2021. However, as shown in the table above, South Africa tested more compared to its counterparts. Various publications have suggested a higher median age of 27.6 years (compared to 19.7 years for Africa), a bigger burden of HIV, tuberculosis (TB), and non-communicable diseases, and urbanization as possible reasons why the country registered more cases. However, a comprehensive examination by the Commission can help fill in the gaps in data.
Emergence and spread of virus variants
The emergence of more transmissible variants of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus, which causes COVID-19, drove the spread of the pandemic in Africa. Specifically, the highly transmissible Delta variant increased COVID-19 cases in Africa in 2021, whereas other less virulent variants – Alpha and Beta – remain widespread across the continent. There are concerns that Africa could become a ‘breeding ground’ for new coronavirus strains as the virus continues to circulate widely due to the slow rollout of vaccines in most countries. And indeed, even since drafting this article two weeks ago, the new variant Omicron has emerged, first identified in South Africa and Botswana.
The Commission’s work could include mapping the entry and regional spread of all the variants reported in Africa. The Commission should examine Africa’s efforts to conduct genomic sequencing to inform its public health responses, as done previously for HIV, polio, measles, among many other diseases. In one example, South Africa stopped administering the AstraZeneca vaccine after it was shown to be ineffective against the Beta variant.
Information on variants also prompted tighter restrictions on movement to control their spread. The Commission could advise how the continent can strengthen its pathogen surveillance to better support the response to any future outbreaks or pandemics. The capacity for this form of testing remains low for many public health programs in Africa. Indeed, the continent has lagged far behind the rest of the world regarding sequencing, with only 1% of over 3 million COVID-19 sequences conducted worldwide occurring in Africa.
COVID-19 response weaknesses fuelled COVID-19 spread
The Commission will also examine how weaknesses in the COVID-19 response, such as poor contact tracing and delayed availability of test results, contributed to the spread of the pandemic in Africa. The World Health Organization’s (WHO) ‘test-trace and isolate’ strategy, which integrates testing to identify positive cases, tracing all their contacts, isolating those infected, and quarantining those exposed, is one of the most effective methods to stop the spread of the virus. WHO recommended that countries trace and quarantine 80% of close contacts within three days of a case being confirmed to curb the spread of the virus effectively. It remains unclear to what extent countries implemented contact tracing. Data sets from Our World in Data suggest that majority of the countries in Africa did not conduct any contact tracing while for others it was limited to a few cases.
In contrast, one study suggests that more than half of African countries introduced a comprehensive contact tracing policy in response to the pandemic, even though some ended up regressing to limited contact tracing. Countries that have recently dealt with disease outbreaks such as the Ebola may have faired better as most had community health workers in reserve when COVID-19 hit. The Commission can examine the use of contact tracing across the continent and draw important lessons from countries that attempted it.
The Commission’s work will be critical for the next outbreak
Outbreaks, particularly those spilling from animals to humans, have been rising in recent decades, including influenza, Ebola, and Zika virus. Models based on historical data show that the next pandemic could be sooner and more severe than the current COVID-19 pandemic. One modelling study estimated a 47-57% chance of another global pandemic as deadly as COVID-19 in the next 25 years. This is due to the increased frequency and severity of spill-over infectious diseases from wild animals to humans.
Despite previous warnings of the likelihood of potential outbreaks and calls to make robust preparations to detect and manage them promptly, COVID-19 caught most countries by surprise, allowing it spread at a rapid rate at the initial stages. The Commission’s work should help correct weaknesses in outbreak preparedness and response in Africa in anticipation of future potential public health emergencies of whatever magnitude. The African-focused Commission, run by Africans, should define and refine the best measures to curb the spread of future outbreaks with due consideration of the African context.