Deadly Synergies

The COVID-19 pandemic has arrived late to Africa. By 24 April there were 17,484 confirmed cases and 784 deaths in 45 out of 47 countries in the African Region of the World Health Organization. This delay has given African countries some time to prepare by implementing public health strategies such as enhancing diagnostic capacity, limiting travel and requiring some forms of quarantine for their populations. While there are varying assumptions about the potential direct impact of COVID-19 in Africa over the next year, there is little reason for optimism. With cases occurring in almost every African country, progression is dependent on the biology of this very new virus, about which we are learning more daily. The virus will tell us.

The impact of the pandemic on the capacity of health systems to provide essential services is predicted to multiply the burden of existing diseases in a dramatic way

The secondary impact in Africa, however, is more predictable and equally alarming. COVID-19 will not just add to the already devastating effects of other infectious diseases in Africa, including malaria, tuberculosis, HIV and measles. The impact of the pandemic on the capacity of health systems to provide essential services is predicted to multiply the burden of existing diseases in a dramatic way. On this year’s World Malaria Day, 25 April, the World Health Organization (WHO) estimates that the potential for disruption of services could result in 380,000 additional malaria deaths that would be indirectly attributable to the COVID-19 pandemic in Africa. This would effectively double the impact of malaria on child survival a year ago.

The effects of COVID-19 on malaria will be felt for different reasons. If preventive measures such as vector control or chemoprophylaxis are interrupted, cases will arise. And if these cases cannot be appropriately managed because people are afraid to seek care, effective personal protective equipment for health staff is not available, malaria treatment is interrupted at the community level, and drugs are out of stock, then mortality rates will also rise. Synergy, in this context, is the worst possible scenario.

Among the lessons learned from previous epidemics in Africa, such as Ebola, it is clear that the disruption of weak health systems can have a devastating effect on mortality from other diseases. The progression of COVID-19 in Africa may not be predictable, but the health impact of the disruption of other services can be examined. WHO with partners has released a report examining the potential impact under nine difference disruption scenarios. The results should call us all to action as never before.

We already know that among the 25 African countries that had planned campaigns to distribute bed nets to prevent malaria in 2020, at least four have decided to reschedule or suspend these campaigns. We also know that management of malaria cases at the community level is threatened by the lack of personal protective equipment for community health workers. There is also a challenge when strategies to prevent transmission of COVID-19 conflict with the need to obtain malaria care, given that fever is often the presenting symptom for both diseases.

WHO has urged malaria-endemic countries to continue with the planned malaria control activities

WHO has urged malaria-endemic countries to continue with the planned malaria control activities as much as possible despite the risk of COVID-19 transmission, and has also published technical guidelines to tailor malaria interventions in the context of the COVID-19 response. In WHO’s words, “the COVID-19 pandemic could be devastating on its own – but this devastation will be substantially amplified if the response undermines the provision of life-saving services for other diseases”.

The COVID-19 pandemic has confronted northern countries with the tragic meaning of having an overwhelmed health system: deaths that could have been otherwise avoided are added to the toll of suffering because appropriate care could not be provided. This is exactly what Africa already experiences under “normal” circumstances. In the case of malaria, around 380,000 people died in 2018 from a curable disease, and there were around 215 million clinical cases of this disease despite the existence of effective preventive measures. The challenge now is to ensure that COVID-19 doesn’t vastly increase the burden of diseases that already affect in a completely unequitable and unfair manner the poorest regions of our common world. The bells should toll for the fewest people possible.