What Africa should do to contain pandemics? A conversation with Ms. Abdullah in Kisumu, Kenya, and with Keith Welkhoff
In Nyalenda, the poor community in Kisumu, Kenya, where Ms. Abdullah lives, malaria is endemic and ubiquitous. Some of her friends developed meningitis after becoming infected; one died. “Malaria has really tormented us as a country,” she said.
Philip Welkhoff, director for Malaria Programs at the Bill and Melinda Gates Foundation, said there was room for optimism. It’s possible to launch a push that will get us all the way to zero.
To better understand their grassroots effort, I spoke with Tomori; Jean-Vivien Mombouli, director of research and production at the Congolese National Public Health Laboratory; and Christian Happi, director of the African Centre of Excellence for Genomics of Infectious Diseases in Nigeria. I wanted to learn, more specifically, what they think Africa should be doing to contain infectious diseases. They offered three key ideas: developing community-based disease surveillance; building capacity to produce protective gear, vaccines, and other pandemic-busting tools; and investing more in health-care workers.
Nonetheless, Tomori rejects the notion that Western philanthropy is the answer. “Don’t buy the story that Africa is poor,” he says. “We’re not poor; it is that we’re not making good use of what we have.”
One of the primary steps toward biosecurity is comprehensive disease surveillance to help rapidly identify and contain novel pathogens — this includes the health-care system treating patients, public health labs conducting tests and epidemiologists coordinating the response. Mombouli thinks the World Bank has spent hundreds of millions of dollars on Africa but it still does not have enough security in its more rural regions, allowing viruses to spread undetected.
The elephant in the room is whether achieving all this is even possible since African public health systems have long been underfunded. As one example, African Union member states pledged to spend 15% of their national budgets on health in the 2001 Abuja Declaration. In only five countries did that happen two decades later.
It took three months for the West African epidemic to be identified, making it one of the worst examples of the disease. WHO reported that the country took so long because “Clinicians had never managed cases. No laboratory had ever diagnosed a patient specimen. No government had ever witnessed the social and economic upheaval that can accompany an outbreak of this disease.” So when the virus was finally identified as Ebola, it was already “primed to explode.”
Mombouli also gives the example of Likouala Prefecture, a swampy area in northern Congo and one of the poorest, least developed regions in the country. He calls Likouala a playground for diseases, from the disease causing bacterium treponema to the infectious disease Rift Valley Fever. He predicts something terrible will happen in that area. It’s only a matter of time without proper pathogen monitoring.
Public health agencies will still have a role to play in helping locals learn, according to Tomori. Those on the front lines of novel diseases may be the ones with the best early warning system. “If you take care of that first case, you can prevent an epidemic,” he says.
With trust built over repeated visits, local hunters began to report the carcasses they found so that the network could test them for Ebola. The end product was a surveillance system that covered 50,000 square kilometers of the most rural regions in the Republic of Congo.
As such, Mombouli thinks the continent should develop its own epidemic “value chain,” a term referring to the entire manufacturing process from acquiring raw materials to distributing finished products. A few African manufacturers have experience making vaccines from start to finish, among them the Biovac Institute in South Africa and theInstitut Pasteur de Dakar in Senegal.
The value chain for health threats has become more difficult to build. In the case of COVID-19 there is a closely guarded secret about the vaccine technology.
“If the company decides to move out,” he says, “then we go back to square one.” Aspen Pharmacare, a Johnson & Johnson partnership, may shut down its South African plant due to insufficient demand because of difficulties in distributing the vaccine.
This will take time, with many things happening in the interim, with the vaccine approval coming in 2024 and much can be done in the interim. African countries can contribute immediately to other parts of the value chain, according to Tomori. One might make glass and rubber containers for testing and so on. Each country doesn’t need to produce everything end-to-end, but Tomori says they should all be starting somewhere instead of patiently waiting for international aid.
Things are beginning to change. Namibia, for instance, is one of four African countries that has surpassed the WHO threshold — with 10.28 workers per 1,000.
The policy does not increase the number of providers, it only improves the efficiency of the health-care system. But in 2010, the University of Namibia established the country’s first school of medicine and has since trained hundreds of practicing doctors “who can respond to the healthcare needs of the Namibian people and are advocates for the poor, underserved and marginalised in our society,” according to associate dean Felicia Christians. The country’s steadfast commitment to progress is emphasized by a call for 50% of the budget to be invested in education and health care.
While it’s critical to continue building more medical institutions, such as the Kenyan General Electric (GE) Healthcare Skills and Training Institute and the University of Global Health Equity in Rwanda, there must also be a focus on retention.
In a 2011 study in the British Medical Journal, it was estimated that sub-Saharan African countries lost $2 billion (in terms of returns on educational investment) because doctors trained on the continent moved abroad. “Africa should start paying people the salaries they deserve, so that they don’t leave the region for other countries,” says Happi. As one example, the Zimbabwean Nurses Association says that most nurses in the country earn only $53 a month, a salary lower than the World Bank’s international poverty line.
This wouldn’t necessarily stop the exportation of health-care workers, but having the West fork over the money could help African countries replenish their workforce. People should be able to say that they can’t deplete a continent’s own resources.
That’s not to say African-Western partnerships shouldn’t be pursued. The omicron variant was found by Sikhulile, the laboratory director at the Botswana-Harvard AIDS Institute Partnership, and a research associate with the Harvard T.H. Chan School of Public Health. Prior to any U.S. hospital having COVID-19 tests, they were deployed in hospitals in Nigeria, Senegal, and Sierra Leone as a result of Happi and Broad Institute collaborating. The $200 million Paul E. Farmer Scholarship Fund was announced recently by Partners in Health and the University of Global Health Equity to educate future health care leaders in Africa.
Simar Bajaj: Science and chemistry in the 21st century, an anthology with an application to computational physics and bioinformatics
Simar Bajaj is an American freelance journalist who has previously written for The Atlantic, TIME, Guardian, Washington Post and more. He studies the history of science and chemistry at Harvard University and is a research fellow at Massachusetts General Hospital. You can follow him on social media.