In December 2019, as the virus spread from China to Europe and America leaving ruins in its path, it was clear that no corner of the world would be spared. By February the first cases were announced in Egypt, South Africa, Nairobi, and soon after the virus had spread across the entire African continent. Western media, to the amazement of Africans, began to publish stories with titles such as the BBC’s “Coronavirus in Africa: Could poverty explain the mystery of low death rates?” of September 2020; or Britain’s Sky News that carried the title asking, “Covid-19 in Africa: Why is the death rate so low? In October 2020, The Africa Report also asked, “Covid-19: Why are Africa’s death rates low? Similarly, abhorrent articles were allowed to pass as “analysis.”
It was as if these media houses were eager to demonstrate the hopelessness of Africans and consequently couldn’t get themselves to cover how Africa was grappling with the pandemic, the variations, and their causes. African leaders defied these expectations of dereliction and took the pandemic seriously within different political, economic, and social constraints. Similarly, the African Union that has for decades been accused of indifference in the lives of Africans mustered the sense of urgency that has always been expected of it but has rarely lived up to. It quickly set up the Africa Centre for Disease Control and Prevention (Africa CDC) and recruited a highly regarded epidemiologist, the Cameroonian Dr John Nkengasong, who up until that time was at the Center for Disease Control in Atlanta.
Since its establishment, the Africa CDC has centralized information and shared it with governments to inform measures to contain the spread of the virus, the process of procuring testing supplies at the very early stages of the pandemic, as well as advice on movement of people inside and outside the continent.
Most significantly, however, the CDC insisted that Africa needed to control its own vaccine resources leading to the set-up of AVAX. It quickly understood that the arrangement of the international community under COVAX was a return to relying on the benevolence of those who would tell Africans “Don’t worry we will get you the vaccines.” In other words, as bad as the problem of vaccine equity has been due to export restrictions on the part of vaccine manufacturers, the situation would have been much worse had it been entirely left to such benevolence. Consequently, Africa CDC is not moving at the pace it had hoped to vaccinate at least 60% of adult Africans, in addition to internal logistical challenges that are affecting rollout capacity and what he calls overhyped issues of vaccine hesitancy that are in his view excuses for those who are not willing to share vaccines.
Time Magazine has named Dr Nkengasong among The 100 Most Influential People of 2021 for his role in Africa’s pandemic response. One can say, therefore, that his work has partly helped to answer the question of why Africans are not dying.
In this interview we ask Dr Nkengasong, what has he done right, what has he done wrong in hindsight, and what should be expected as Africa continues to confront the pandemic.
PAR: How prepared was Africa for the pandemic, and how does that reflect in how it is managing it?
Unfortunately, because of our weak healthcare systems, Africa was not prepared for such a pandemic; I mean, not at all. Our health systems continue to be challenged by even endemic diseases which we had before Covid-19 (such as HIV, TB, and Malaria) and the rising rates of non-communicable diseases like cancer, diabetes, and hypertension. So, with such a fragile system, it is hard to say that Africa was prepared. However, Africa reacted very quickly to the pandemic and actually was privileged because we saw this happening, like a fire that spread from China, beginning from December 2019, to Europe, and by the time it arrived in Africa, on the 14th of February 2020 in Egypt, we knew it was coming.
At that time, at the AU’s Africa Centres for Disease Control and Prevention (Africa CDC), we had selected experts from nearly all the countries that had direct flights with China and trained them in Senegal on how to do diagnosis for Covid-19. There were really no countries that had the capacity to test for Covid-19; by capacity, I mean the agents to test were not there because, otherwise, there are many labs in Africa.
And luckily, when the first cases were reported in Egypt, the experts trained in Senegal with the Africa CDC were on hand to start doing the testing with the test kits that we had shipped to them.
We later had another training for African health professionals in South Africa, and then the whole continent was able to test for Covid-19. So, the point I’m making is that even though the continent was not prepared, we moved into full-scale action because we knew it was going to hit us. There’s a paper that I can send to you which I wrote in January and published in Natural Medicine (at that time, there were about 200 cases in the whole world and only around China, Thailand and Hong Kong), where I advised that Africa would need to be prepared because this virus would show up on the continent, and it did. This shows how quickly viruses can spread and how a threat anywhere in the world is a threat everywhere in the world.
Another important yet often unaddressed point that must be made about Africa is political leadership. President Ramaphosa, who was chair of the African Union, convened about 15 meetings of heads of state to talk about the Covid-19. He appointed special envoys like Donald Kaberuka, Strive Masiyiwa, Ngozi Okonjo-Iweala, etc. He set up the Covid-19 response team and the African medical supply platform spearheaded by Mr Masiyiwa, with most countries on the continent joining the initiatives. Our role at the Africa CDC was to elaborate a continental strategy. Ramaphosa’s part was to champion that continental strategy with all of these elements that I’ve just listed and that were all accredited under his political leadership.
Let me conclude by saying that the first cases showed up on the continent on the 14th of February. On the 22nd of February, we convened an emergency meeting of all ministers of health in Addis Ababa. Some ministers who were travelling to Europe had to return to Addis Ababa because they recognized that it was important and urgent. When they left on the 22nd, they left with the clarity of purpose and action. They were given clear instructions about what to do when they return to their countries and see any cases.
The continental skies were shut down in March and April of 2020. Why was that important? It was important not because that is how you fight a pandemic but because we had nothing. We had no diagnostics. By March 2020, as a continent, we had conducted less than 200, 000 tests on a continent of about 1.2 billion. So, we had to take those measures in order to enable us to stockpile the Covid-19 response materials and resources (like the PPEs, masks, equipment for diagnostics). That political leadership and the joint continental strategy that we developed were very important. The heads of states endorsed the continental strategy, which was underpinned by cooperation, coordination, collaboration and communication.
PAR: What has happened since? Because, as you can see, some of these countries in the west are talking about a post-Covid-19 economy. They are back to getting off the masks; they are back to normal life. And for us, it appears we are going in the other direction. What is happening?
You know it is very hard to contain these viruses with only public health measures because you have to balance between saving lives and saving livelihoods. The only reason that those countries are beginning to look normal (for instance, you and I are now watching the European nations cup and young people like you are in the stadium shouting, jumping and hugging) is because of vaccination. They have vaccinated large chunks of their population. Africa has only fully vaccinated about 1 or 1.5 per cent of its population, which is extremely limited. So, I think that is a very important consideration. So, I mean, we did what we could do. What we were doing in public health measures was to hold a front, keep blunting the spread of the virus as much as possible while waiting for medical interventions, which unfortunately has been extremely delayed.
PAR: Let’s talk about that delay — this vaccine nationalism. I saw a clip by Strive Masiyiwa talking about these countries hoarding vaccines and having more than they need. We are used to a world where these countries promote a liberal trade environment, meaning that if you have the money, you should be able to access what you are looking for. What is happening?
I would say that several headwinds have blown against us Africans. First of all, it is our inability to manufacture vaccines. We import 99 per cent of our vaccines, produce 1 per cent of the vaccines that we consume, and consume 25 per cent of the world’s vaccines. So, when you are hit by this pandemic, and you are relying on somebody else to produce the vaccines – someone who must immunize their own people – to work with you and ensure scientific cooperation and solidarity, you always suffer. That is one.
The second is that when the pandemic started, we said all the right things: fair access to vaccines, and then we set up the COVAX mechanism, which is a mechanism pioneered by the global vaccine alliance, WHO and the Coalition for Epidemic Preparedness Innovation. The intent of the COVAX mechanism was to have a programme which, in my view, was a strong expression of solidarity and cooperation; but the implementation was below expectation. For example, rich countries pledged money to COVAX but bought vaccines. So, whereas COVAX was sitting on billions of dollars, they didn’t know where to go get vaccines because they were competing with the same people that had given the money. And Africa was waiting and relying on those public pronouncements that the vaccines would be available to COVAX, from which we hoped to vaccinate 20 per cent of our population. I think that is when it became challenging.
Africa believed that their own health security would be taken care of through a global mechanism. The first lesson we should learn as a continent is that you must take charge of your health security. I use the word “must” deliberately.
We saw this in 2009 when the swan fever pandemic broke out. Vaccines were available in the west. They were only available in Africa and in other developing countries when the pandemic was over. Fortunately, the pandemic didn’t last.
We saw this in 1996 when drugs to treat HIV patients were available in the west, and the rate of mortality was plummeting in the west, but in Africa, it took us 10 years between 1996 and 2005 before ARVIs became available. I remember it vividly; I was already at a mid-career level in public health in Cote d’Ivoire at the time. My office was overseeing infectious diseases in Cote d’Ivoire, and people would drive in, drop their loved ones who were infected with HIV, and go away because there was no money. At that time, it cost about ten thousand dollars to treat a patient per year. Over that period of ten years, about 12 million Africans died of HIV/AIDS. Africa is used to being a moral dilemma for humanity, and it is very unfortunate. So, Africa should learn from that, and that is where we are pushing: there must be a new public health order for the continent.
A new public health order for the continent that does 5 things. One, we coordinate ourselves to begin to manufacture vaccines, therapeutics and diagnostics. Second, we invest in workforce capital so that we have a functional public health workforce on the continent. You can only help yourself; I mean, nobody else can help you, especially during a pandemic. You cannot expect the Europeans, instead of fighting their own pandemic and outbreaks, to descend to work with you. That’s the reason behind the creation of Africa CDC, which is one of the greatest visions of our heads of state.
Third, to strengthen our own national public health institutions, like the CDCs in Africa. Every country should have its own CDC. The fourth thing is that we must work with the private sector, work with the likes of Strive Masiyiwa and others so that we can harness the power of innovation to address the power of our public health issues. Lastly, work with our partners in a way that is respectful, that we honour our vision and the direction that we agreed on. Those are the 5 pillars that we have set; a new public health order must emerge so that we build back better, we build back stronger, and we build back bigger.
PAR: You said that those HIV/AIDS-related deaths were preventable. Now we seem to be in a similar situation as you have just said. So, I’m worried. How worried are you? Are we going to lose a similar number of people to another preventable situation?
I’m very worried, but I remain optimistic. I am worried because this virus is very dangerous, it spreads very quickly, and we have already had a considerable delay in our ability to roll out vaccines. And my fear is that we may move into the endemicity of this virus, which means that the virus becomes very difficult to flush out. Again, we cannot live with this virus. It is not HIV; it is not TB. It disrupts economies, it disrupts lives, and it kills. The mortality is very high. So, I’m very concerned that the delays will lead to a situation where the virus becomes endemic.
But I remain hopeful. Through the efforts that we have just described (for instance, the African Vaccines Acquisition Trust (AVAT) that Mr Masiyiwa is heading), we have secured 400 million doses of Johnson & Johnson and the delivery will start in early August 2021, and it will be very predictable and consistent so that by the end of the year you will see a significant number of our people being fully vaccinated. We need that predictability to be able to plan and scale up vaccines. For instance, if you go to Kigali and tell people to go get their vaccines and they don’t find the vaccines, the next time you tell them to go, they will not go. That is the utility of the predictability of vaccination that we want to see. In Rwanda, for example, the first doses of AstraZeneca arrived, and within two weeks, they were all used. About 290, 000 doses disappeared, just like that. For Pfizer, a batch of 102,000 doses; and 50,000 doses were gone within a short while. When I was in Kigali, in the vaccine warehouses, you could only see the freezer that was standing there and was full of doses that were waiting for the second immunization. So, it can be done in Africa.
We should not accept this characterization that Africa is not using its vaccines because of vaccine hesitancy. Throw in vaccines in Rwanda, Nigeria, Ghana, Togo, Kenya; they will be gone within a month. The narrative that vaccine hesitancy is delaying the vaccine programme is false. People don’t even have the vaccines, so how can they not use the vaccines?
We have seen in countries like Cote d’Ivoire where there was initial reluctance, but when people saw that the first set of people who received the vaccines were okay, you could see the rate of acceptance rising. Africans are used to vaccination. We live in a hostile tropical environment, so that is the only way we survive. So, we are not going to accept that characterization that we are a continent that is driven by vaccine hesitancy.
PAR: I am interested to hear your view on what you think drives that myth about hesitancy. Also, you could talk about the logistic challenges. To what extent have they been an impediment to effective vaccination.
The logistic challenges are there because, as a continent, we have never immunized about 200 million adults in one year. Remember, the vaccines that we are used to receiving are vaccines for childhood immunization. Even vaccination for yellow fever, which you need for travel, is not done on a large scale. But Africa is a resilient continent. We can use those vaccines; I just cited the cases of countries that organized themselves. It’s a question of organization. You set up vaccination centres, you pull young people from medical schools who are at the end of their training, bring out those who have retired (nurses and doctors), and that gives you a capacity, and you get it done. I mean, it is not impossible to roll these vaccines out, but we have to have a predictable source of vaccines so that we can plan. You don’t plan in a vacuum because some of these vaccines come in minus 20 degrees, some come in minus 80 degrees. But it can be dealt with. Communities are very resilient; they can easily work with us if they see value in what we ask and work with us in the public health sector to roll out vaccines very quickly. The logistics are there — we need to factor in the scale of vaccination, but it is not an impossible task.
PAR: On the myth around vaccine hesitancy, what is driving that myth?
It’s just that people are mischaracterizing us; I don’t know what the undertone there is. Let me give you facts. As a continent, we have received about 61 million doses of vaccines. Of that number, 80 per cent of the vaccines have been consumed, which tells you that if the vaccines are here, we will use them. Are there pockets of resistance there? Yes. But it’s unfortunate that anyone would take a pocket of resistance somewhere and project it as the continental hesitancy; that is the myth there which people are trying to play out, saying, “these Africans are not using the vaccines.” That is not correct.
PAR: You mentioned that manufacturing is a key answer to the issue of the predictability of vaccines. How hopeful are you that this is going to be implemented? In the past, we have had situations where the answer is clear, but the ability to mobilize is …
No, we are mobilizing now. The starting point was the historic meeting we had on 12 and 13 April 2020, where forty thousand participants gathered on a platform. During this entire pandemic when we started using platforms, I am yet to see a platform that brings together forty thousand people. What was it? It was a vaccine summit: vaccine manufacturing in Africa. Four heads of state were present: Ramaphosa, Tshisekedi, Kagame and Macky Salle. That was a historic moment. Since then, what has happened? There’s a hub now in South Africa for manufacturing; Rwanda has a strong will, political capital, and a strong determination to start manufacturing vaccines, and we are very supportive. The same can be said for, Senegal. Egypt is already building a partnership with the Chinese to manufacture the Chinese vaccine. I was just told today that Morocco is in the process of manufacturing vaccines. What’s more, Algeria and Ghana are also eager to do that. Last week, we had a meeting of about 12 African countries that all came together, and we said, “look, if you all want to manufacture vaccines, come together and let’s have a conversation.” They all came together and we had a conversation. So, we are making progress; it is a fact that we will make this happen.
PAR: We hear that the vaccines might not get to all of us until 2025. What reassurance can you give Africans? Some hope about…
No, absolutely not. Africans, we are a resilient people. Count on your own; you have counted on us, you trusted vaccines; we’ve started rolling out vaccines in a very systematic way, starting from August 2021 with the AVAT mechanism. The other donations and pledges can come in to support, but the backbone of our vaccination programme will be driven by ourselves, the AU and the AVAT mechanism. And again, just next week, we will begin to see the distribution of some doses that are coming from Johnson and Johnson, which will be vaccines that have been procured and paid for by Africans for Africans. We will not wait until 2024 or 2023; you can be assured of that.
When the vaccines are available, please go get your vaccines. If you vaccinate yourself, you are vaccinating and protecting your loved ones. If you vaccinate yourself, it means you love your neighbour, your family, your loved ones. It is not just about protecting yourself but protecting your loved ones and your community.