Technical Director, Demographic Research
June 10, 2020
Technical Director, Demographic Research
Principal, Clarity Global Health LLC
Since then, it has spread at an alarming rate, with more than half of countries in the region now experiencing community transmission—when new cases occur without any known contact with someone from an infected area.1 South Africa leads the region with nearly 40,800 confirmed cases as of this writing, followed by Nigeria (11,500), Ghana (8,900), and Cameroon (7,400).2
Although the region is still reporting fewer cases of COVID-19 than the rest of the world, the wide geographic spread of infection suggests a large number of unreported cases and deaths. In addition to governance and health system structures, other regions’ experiences offer general models for how the pandemic may play out, but sub-Saharan Africa’s specific characteristics related to age, health, and lifestyle will affect its trajectory in both positive and negative ways. Here’s what we’re keeping an eye on as we monitor the pandemic in collaboration with our partners in the region.
Evidence shows that older populations are hardest hit by the coronavirus. Sub-Saharan Africa has a much younger population than China, the United States, the European Union, and other areas already experiencing widespread infection. The median age is 38 in China and the United States, and 43 in the European Union, but it is just under 20 in sub-Saharan Africa.3
Only 3% of the region’s population is over age 65, the threshold for significantly higher risk of COVID-19-related complications and death.4 In Italy, which has had one of the highest COVID-19 mortality rates in the world, 23% of the population is over age 65. In contrast, in Nigeria, Africa’s most populous country, 44% of the population is under age 15—a group that has thus far been spared the worst of the pandemic (see figure).
According to modeling by the Center for Global Development, assuming a worst-case infection scenario without government intervention, 1.3% of Spain’s population would be killed by the epidemic compared to 0.15% of Uganda’s based on differences in the country’s age distribution alone (assuming the relationship between age and mortality and all other factors are the same).5 While we know that health and other factors come into play, sub-Saharan Africa’s youthful age structure could contribute to a lower regional mortality rate.
FIGURE. Sub-Saharan African Countries Have a Much Younger Age Profile Than European Countries
Sources: PRB analysis of data by the United Nations, World Population Prospects: 2019 Revision.
Other demographic features in sub-Saharan Africa, however, could complicate prevention and mitigation efforts related to COVID-19.
Migration. When people travel the continent by land and air, they pose a significant risk of carrying the coronavirus with them, undetected, into neighboring countries. South Africa, Kenya, and Ethiopia are travel hubs for the rest of the continent, creating a situation where people may move from higher prevalence areas to lower prevalence areas, driving the spread of infection. When South Africa declared its lockdown in late March, for example, it sent 14,000 Mozambican workers back across the border.6 West Africa is particularly vulnerable, having both the most migrants and the most reported cases of COVID-19 as of this writing.7
Displaced persons. The United Nations Refugee Agency reported in 2019 that sub-Saharan Africa hosts more than 17 million internationally displaced persons and six million refugees—more than a quarter of the world’s refugee population.8 Such a high number of displaced persons, who are more likely to live in close quarters with others and often in conditions with poor sanitation and hygiene, limits countries’ abilities to monitor infection rates and enforce preventative measures such as physical distancing.
Rapid urbanization. Physical distancing is challenging in urban areas with high population density. These difficulties are especially acute in sub-Saharan Africa, which is experiencing the fastest rate of urbanization in the world and anticipating 65 million additional urban residents each year.9 More than half the region’s city dwellers live in slums or informal housing known for unhygienic and crowded conditions, and 63% of city residents lack access to clean water and soap for frequent handwashing.10 As a result, basic precautions against COVID-19 recommended by the World Health Organization may not be feasible for a large portion of the population.11
Large households. With an average household size of 6.9 people, multigenerational households are more common in this region than in any other.12 Such housing arrangements—in close quarters with children and working adults—could put older individuals at heightened risk of infection and death from COVID-19. In West African countries such as the Gambia and Senegal, for example, households with at least one older family member had an average of 12 residents.13 Even when at-risk individuals can avoid nonessential interactions outside the home, their family members pose an infection risk in shared spaces.14
Experience with other infectious disease outbreaks has given some countries in sub-Saharan Africa a head start in terms of preparedness and health infrastructure to slow the spread of the coronavirus. In late February 2020—nearly a month before countries in the region implemented widescale social distancing measures—the new Africa Centres for Disease Control created a continental plan to train health care workers in 48 countries to process coronavirus tests.15
At country levels, recently established and strengthened public health organizations such as the Nigeria Centers for Disease Control have redirected existing disease task forces and resources to the coronavirus containment effort.16 Resuming procedures established for the 2014 Ebola crisis, for example, the Democratic Republic of the Congo (DRC) swiftly implemented screening, testing, and contact-tracing procedures and readied its bio-secure emergency care units.17 Uganda, which has operated in a state of health care emergency since 2018, mobilized border surveillance teams and screened travelers at its principal international airport using surveillance staff and thermometers on hand from combatting past diseases such as yellow fever, measles, and the Crimean-Congo hemorrhagic fever.18
These early preparedness measures may help countries in the region slow and contain the spread of the coronavirus.
Existing health conditions. Aside from age, a person’s overall health plays a major role in determining how COVID-19 symptoms manifest. In sub-Saharan Africa, a wide range of diseases have wreaked havoc on individuals’ immune systems. Specifically, infectious diseases such as HIV/AIDS and tuberculosis disproportionately affect people in the region and may potentially put the population at higher risk of suffering severe complications from COVID-19, especially if treatments for these diseases are interrupted. In 2018, the region claimed 24% of the 10 million cases of tuberculosis, including 72% of co-infection cases in vulnerable HIV-positive individuals.19 Sub-Saharan Africa is home to two-thirds of people living with HIV worldwide.20 Notably, 89%, or 1.5 million of the 1.6 million adolescents living with HIV worldwide, are in sub-Saharan Africa—a vulnerability that could potentially erode Africa’s otherwise youthful advantage against the coronavirus.21 Research has shown that adolescents have particular difficulty adhering to the treatment regimens that suppress HIV, making them more vulnerable to other infections.22
The region also has high rates of noncommunicable diseases (NCDs), which have grown substantially in recent decades as a proportion of the total disease burden. The single largest category of NCDs are cardiovascular diseases such as ischemic heart disease, hypertension, and high blood pressure, all of which increase the risk of becoming severely ill from COVID-19.23 High rates of smoking and unhealthy diets, common in African countries with relatively higher rates of urbanization, also contribute to this health burden. Recent studies estimate that 5% of sub-Saharan Africans have diabetes and 20% are obese.24 In addition, individuals develop NCDs at much younger ages in sub-Saharan Africa than in high-income countries, PRB reports, possibly exacerbating the pandemic’s impact on the region.
“Critical immunization programs and malaria prevention activities have been sidelined as health care workers and resources are diverted to combat the COVID-19 pandemic.”
Health systems capacity. Despite its past experiences with disease outbreaks, the region’s limited health care infrastructure, including weak supply chains, shortages of health personnel, and low testing and laboratory capacity, will make it difficult to respond to the coronavirus pandemic. Public health care spending in Africa is among the lowest in the world, with an estimated $66 billion in unmet needs, according to one study.25 Although health care capacity varies widely among sub-Saharan African countries, on average, the region has only 0.2 doctors for every 1,000 people compared with 1.8 in China and 3.7 in the European Union.26
Many health care facilities in the region lack electricity and essential medicines, and few countries have sufficient intensive care units (ICUs) to treat the critically ill.27 Uganda has just 0.1 ICU beds for every 100,0000 people.28 The United States, where many hospitals are at risk of reaching capacity with COVID-19 patients, has 35 ICU beds. The supply of ventilators is further restricted. Even fewer countries in sub-Saharan Africa have enough ventilators, the life-saving equipment required to treat the most severe cases of COVID-19. As of March 2020, for example, Liberia did not have a single ICU equipped with ventilators. An International Rescue Report in April 2020 found that South Sudan had four ventilators for its population of 11 million and Burkina Faso had 11 ventilators for its 20.9 million people.29
Although international aid is helping close these gaps, all external sources of funding and resources will be constrained as the coronavirus spreads around the world. And as health facilities ration supplies of personal protective equipment for COVID-19 cases, their capacity to care for patients with tuberculosis and other infectious diseases will decline.30 Critical immunization programs and malaria prevention activities have been sidelined as health care workers and resources are diverted to combat the pandemic.31
Most sub-Saharan Africans cannot work from home or practice physical distancing in their jobs because of the kinds of work they do. Seventy-seven percent of non-farm employment in the region is informal, the highest percentage in the world.32 Small business owners, merchants, and vendors who rely on income from each day’s work to meet basic needs for themselves and their families—without employment benefits or social protection—cannot easily abide by government directives like shelter-in-place orders.
Some countries have introduced measures to lessen the economic impact of the coronavirus restrictions and incentivize distancing, including emergency cash payments to the recently unemployed in Namibia and Cabo Verde and widespread tax relief in Kenya.33 These efforts are relatively minor, however, and will be difficult to sustain in the wake of future pandemic-related economic shocks and market interruptions. The potential for public income support that can encourage people to stay at home is extremely limited for most countries because of underfunding of social programs and high levels of public debt.
In light of these conditions, COVID-19 mitigation strategies are being adapted for the sub-Saharan African context. Many African countries have already implemented physical distancing measures such as curfews, city lockdowns, and travel restrictions. Nigeria, Zimbabwe, and South Africa were some of the earliest countries to initiate lockdowns that limited travel and closed nonessential businesses.34 Across the continent, many places of worship have closed their doors or implemented outdoor services that comply with physical distancing requirements.
In some places, however, social resistance to preventative measures threaten the success of curfews and lockdown measures.35 Protestors have had violent clashes with police in Kenya and South Africa over restrictions.36 In Malawi, personal rights concerns have led high courts to block lockdown measures from being enacted until a social safety net is in place.37 Ghana, the DRC, and other countries began easing restrictions early on in response to economic hardships and what they perceived as slow rates of infection, followed by South Africa beginning in early June.
Balancing health and economic considerations is an enormous challenge for every country battling this pandemic, but sub-Saharan Africa’s unique characteristics mean that countries might pursue different strategies than those adopted in other regions. Monitoring how the region’s demography and health characteristics shape the course of the pandemic, and exchanging lessons learned across countries with similar profiles, is critical for policy and program responses to integrate the latest evidence.
The authors would like to thank Kaitlyn Patierno, Barbara Seligman, Lara Vaz, and Laura Wedeen for their helpful comments and suggestions. We also appreciate the research support provided for this article by Omaris Caceres, Elaine Les, and Kate Rogers from Georgetown University.