Pandemic downsides abound amid ‘vaccine apartheid’ A second Covid-19 surge is putting to the test assumptions that the pandemic’s public health impact across the continent has been comparatively mild. Health crises and on-and-off lockdowns may be a recurring feature of 2021 and beyond, if (or perhaps when) fresh Covid-19 surges materialize. To date, the region is lagging so far behind in the global scramble for vaccines that it could take years to reach a significant vaccination threshold, posing downside risks to the region’s economic recovery as well as global public health. Second wave hits harder A second Covid-19 surge is putting to the test assumptions that the pandemic’s public health impact across the continent had been relatively light, thanks to factors including early lockdowns and the demographic advantage of youthful populations. In 2020, the continent – with 14% of the world’s population but only 3% of known Covid-19 cases and deaths – appeared to have been affected by the pandemic much less than other regions.
The main caveat has always been that data remains sketchy in light of limited testing. In fact, merely eight countries account for 75% of all tests, according to Brookings. Nevertheless, there is growing concern that the second Covid-19 wave appears to be taking a heavier toll. In late January, the Africa Centres for Disease Control (Africa CDC) stated that the region’s case fatality rate (CFR) had risen to 2.5%, above the 2.2% global average, while 21 African countries now report CFRs above 3%.
South Africa, with the highest levels, has been particularly hard hit by a second wave, which has been largely driven by the B.1.351 variant (also known as 501Y.V2) that was first identified in South Africa. The wider Southern African sub-region now accounts for nearly half of all reported cases on the continent. In Mozambique, of all Covid-19 deaths to date (367), more than half (201) occurred in January alone. Overall infection and hospitalization rates have risen accordingly, with hospital shortages much more acute than during the first wave. In Nigeria, more than half of confirmed Covid-19 cases have been registered since November 2020 and the second wave has caused oxygen shortages in hospitals nationwide.
Like elsewhere, this has forced policymakers, particularly across Southern Africa, to rethink their reluctance around lockdowns and restrictions. After early lockdowns in 2020, highly restrictive measures came to be considered difficult to enforce, particularly in a context of large informal economies and limited social safety nets. Yet the worsening Covid-19 surge is forcing fresh restrictions, though policymakers will likely continue to prefer more flexible measures over hard lockdowns. This includes night-time curfews, land border closures or testing requirements, and limits on social gatherings.
Across West Africa, where public perception still appears to be colored by the notion that Covid-19 is a ‘white man’s disease’, governments are more reluctant to tighten measures. While Nigeria merely rolled over the ‘eased lockdown’ status introduced in September 2020 by another month in late January, Ghana reopened its schools by mid-January yet reintroduced some restrictions on public gatherings. Senegal – already among the most proactive West African countries in 2020 – has gone the farthest by imposing an extended curfew in Dakar and Thies.
Looking ahead, health crises and on-and-off lockdowns may well be a recurring feature of 2021 and beyond, if (or perhaps when) third or fourth waves materialize. Indeed, a scenario of successive Covid-19 surges appears to be the baseline assumption of health officials in countries like South Africa, unless there were quick and effectual progress on the vaccine front.
Vaccine apartheid Yet thus far the region’s vaccination outlook is the bleakest worldwide. Direct vaccine procurement is lagging far behind. To date, no country in sub-Saharan Africa has started vaccinations, with the exception of the Seychelles and Mauritius, which have benefited from vaccine donations from India and the UAE.
For the vast majority of countries, the World Health Organization (WHO)/Gavi COVAX initiative will be the primary source of vaccines, but its reach remains limited. According to COVAX’s January Global Supply Forecast, only 540mn vaccine doses are currently secured for the African region. The African Union (AU)’s African Vaccine Acquisition Task Team (AVATT) has secured an additional pool of vaccines, which stands at 270mn doses, with another 400mn doses in the pipeline. These are to be distributed on a population-size basis. One challenge will be financing. For while the African Export-Import Bank will provide guarantees, cash-strapped governments will struggle, putting the onus on corporate donations. In terms of timing, the bulk of COVAX and AVATT-supplied vaccines are only expected to arrive in H2 2021. Above all, the amounts secured to date are a fraction of what will likely be needed if the goal is to inoculate two-thirds of a population of 1.3bn. A Duke Global Health Institute study estimates that “most people in low-income countries [including sub-Saharan Africa] will be waiting until 2024 for COVID-19 vaccinations.”
Even South Africa, which is slightly better positioned in the regional context, faces harsh criticism at home for delays to its vaccine procurement and rollout. The government now claims to have some 40-50mn vaccine doses in the pipeline, including COVAX and AVATT allocations, which could go some way towards meeting its ambitious goal of vaccinating 40mn South Africans in 2021. However, a new wrinkle is a scientific study indicating that the Astra Zeneca vaccine provides minimal protection against mild to moderate disease caused by the B.1.351 variant. The latest findings threaten to upend South Africa’s imminent vaccination rollout, which aims to inoculate 1.25mn medical workers in phase 1. Vaccine efficacy could thus present a significant downside risk to vaccine procurement and rollout strategies.
Nevertheless, vaccination campaigns will remain the top priority. The Africa CDC has previously warned that Covid-19 could become endemic in the region if the vaccination process takes four to five years. The rising risk of global vaccine apartheid has resulted in a surge of appeals, including from WHO Director-General Dr Tedros Adhanom Ghebreyesus, against vaccine nationalism by high-income countries, on the grounds that it risks prolonging the global pandemic. At the World Trade Organization (WTO) level, South Africa, together with India, has been lobbying for a waiver of IP rules regarding Covid-19 vaccines and treatments. Rich countries’ opposition to the proposal has been steadfast. It remains to be seen how Nigeria's energetic incoming WTO secretary-general, Ngozi Okonjo-Iweala, may galvanize the debate around global vaccine distribution and equity. (The next meeting of the WTO’s TRIPS Council is scheduled for 23 February.)
Vaccine diplomacy Misgivings about the West’s hoarding leave the door wide open for Eastern competitors’ vaccine diplomacy as cash-strapped governments struggle to source sufficient vaccine supplies beyond their COVAX/AVATT allocations. Nigeria, for instance, has confirmed interest in vaccines from China, Russia and India. Guinea became the first regional country to certify Russia’s Sputnik-V vaccine in January, following a brief experimental campaign.
The region’s vaccine outlook might improve if China’s and Russia’s vaccines receive prequalification (PQ) status from the WHO. This would also bolster Russia’s and China’s opportunities to play vaccine diplomacy vis-à-vis the US and European countries. Already, the Chinese government has donated 10mn doses of the Sinopharm vaccine to the COVAX initiative, and is reportedly in talks with numerous regional governments including Senegal, Cote d’Ivoire, DR Congo and Zimbabwe. Meanwhile, Ethiopian Airlines has set up a logistics partnership with China’s Alibaba to facilitate distribution of the Sinopharm vaccine across the continent.