EXPERT OPINION: Global public health experts Dr David Bell and Muhammad Usman Khan ask whether millions of young Africans need to be vaccinated – and for whose benefit?
Child mortality will almost certainly rise across sub-Saharan Africa this year.
The singular focus on Covid-19 has resulted in an interruption to all other healthcare – as well as growing levels of malnutrition, thanks to lockdown-induced job losses and poverty.
The World Health Organization (WHO) was at pains to reassure children in developed countries of Father Christmas's immunity to the virus in December, so as not to ruin their year.
Meanwhile, little focus has been given to African children, increasing numbers of whom have been orphaned by HIV/Aids and tuberculosis during the pandemic.
Sadly, the global health community that, in the past, prioritised HIV/Aids, tuberculosis (TB) and the big child killer, malaria, appears to consider avoidable deaths from such illnesses an acceptable cost in their attempt to reduce transmission of SARS-COV-2.
This paradox is especially true in Africa, where more than 50 per cent of the population is under the age of 19, and additional factors such as the climate, low levels of obesity and other comorbidities, may have left most Africans effectively protected from Covid-19.
In spite of this, influential organisations in global health are calling for restrictive measures to continue until a Covid-19 vaccine is available and all are vaccinated – sometime in the coming years.
With wealthy countries and private philanthropy planning to divert large donations to this cause, and a global alliance under the COVAX umbrella gearing up to lead it, there is an urgent need to examine whether this is of benefit to Africa.
The virus, SARS-COV-2, was initially feared to be highly lethal and capable of killing up to one in 20 infected people.
The initial mortality rates for northern Italy’s elderly looked frightening when transferred to the entire population of the African continent.
Governments, corralled by the WHO, narrowed their focus on dealing with what was initially presented as an existential threat to medical infrastructure around the world.
But as more data poured in, it became clear that the challenge the virus presented, although serious, was not the global catastrophe previously feared.
Yet seemingly undeterred by emerging data – the infection fatality rate is now estimated at 0.23 per cent, and far lower for those under 65 years of age – global health institutions and governments continue to allocate hefty resources and a blinkered focus on the pandemic with undiminished urgency.
Half of the billion-plus people in sub-Saharan Africa are under 19 years of age, and we know that most infections in children are barely symptomatic.
Regardless, a climate of fear is being sustained with the media still whipping up fear of a looming ‘catastrophe’ for African countries.
When most European nations locked down their populations, copying the highly restrictive measures employed in China, the WHO advocated similar measures across Africa.
This ran contrary to its own prior evidence-based pandemic guidance and with seemingly little regard for the high vulnerabilities to pre-existing epidemics, such as malaria, TB and HIV/Aids, as well as the limited capacity of these populations to absorb income loss.
The catastrophe currently unfolding in Africa is not due to the coronavirus.
Despite months of community spread in crowded cities, recorded Covid-19 mortality was under 70,000 across the entire continent by January 1, 2021.
If we exclude the Mediterranean countries and South Africa with their differing demographics and high comorbidities, just 13,031 people died of Covid-19 in the rest of the continent in 2020 – that’s approximately one death for every 80,000 people.
As the figure shows, Covid-19 would likely have gone unnoticed in Africa if we had not been testing for it.
The virus has dominated the policies of donors and international organisations on an unprecedented scale, and while African countries may be easing internally, the focus externally remains on Covid-19, and a vaccine whose roll-out in these populations would defy all previous public health norms.
This catastrophe goes far beyond health alone.
A generation of children’s schooling has been interrupted. Children from poor and rural families will likely never recover.
Even more alarmingly, girls and young women have been pushed back into the trap of early marriage and poverty.
Without any serious pushback from its staff, the World Health Organization and wealthy philanthropic foundations have advocated for policies that impoverish, restrict and reduce healthcare access, abandoning previous recommendations advising against such measures.
In a new form of post-colonial oppression, the rich world, via video meetings on Zoom, have introduced policies that are leading to impoverishment in Africa.
The rise of large private philanthropies, who arguably dominate the current global public health agenda, has undoubtedly brought great benefits in terms of almost unlimited funding, new ideas and enthusiasm, though this may not always be fully aligned with local priorities.
Vaccines are a perfect example of this.
In recent months, the world has been focused on the development and trials of vaccines for SARS COV-2, in the hope that they will allow a return to normality.
This had led to a poorly considered campaign of mass immunization being promoted, despite the current lack of evidence that the vaccines have a transmission-blocking effect.
If vaccines don’t stop onward transmission, and just lessen symptoms, it essentially means we will not be vaccinating children for their own health, but in order to protect a small cohort of elderly citizens.
And given the very low impact of Covid-19 on younger people, and thus on the vast majority of Africans, one has to question why a vaccine for Covid-19 should take precedent over investment in mosquito nets for malaria, for instance.
A Covid-19 vaccination programme will inevitably reduce the amount of money and manpower to prevent far worse diseases that African children face.
Foreign aid from increasingly cash-strapped donor countries is already being sought for the COVAX mechanism in the name of global equity, while local health staff, logistics and expertise will be drawn from other pressing areas to help vaccinate against Covid-19.
To justify this approach, some pressure groups are claiming that people in sub-Saharan Africa need to be vaccinated in order to reduce the risks for those living elsewhere.
If we believe the SARS-COV-2 virus can and should be eradicated globally, but we recognise that diverting resources for this programme will cost lives, then we need to acknowledge that the children who are no longer benefiting from other health interventions, are dying for the benefit of mostly elderly and chronically sick people in far wealthier nations, who wish to reduce their own Covid-19 risk.
This may not be ‘wrong’, if the benefit to Africans can be shown to outweigh the costs.
But clearly, if this is not demonstrated, then the equity argument behind COVAX and the universal Covid-19 vaccination programme becomes unsustainable.
Those of us in the global health community need to pause, question and think for ourselves.
By any normal measure, we are catastrophically failing the people we were entrusted to serve.
The current approach appears to be causing net harm, and African health is at risk of being crushed under a model designed by and for others.
Covid-19 is a chance to reset, but not through the deaths of children and the impoverishment of tens of millions.
Fixing this will take humility and self-awareness.
To build a better future, we first need to avoid doing more harm. Let’s hope, collectively, we have the courage and moral decency to undo the mess we have created.
Then we must support the people of these countries in continuing the broad improvements in health care upon which they, with admirable support from both public and private sectors, had previously embarked.
Dr David Bell is a clinical and public health physician with a PhD in population health. He was Director of the Global Health Technologies at Intellectual Ventures Global Good Fund in the USA, Programme Head for Malaria and Acute Febrile Disease at FIND in Geneva, Switzerland, and coordinating malaria diagnostics strategy with the World Health Organization.
Muhammad Usman Khan is a health policy analyst. Usman has consulted and worked in advisory roles for multiple governments and NGOs.