Africa has so far been spared the worst of the coronavirus. That could soon change.

“I don’t know what ‘flattening the curve’ really means in this part of the world,” one expert told Vox.

The African continent is extremely vulnerable to a large-scale coronavirus outbreak, but not just in the way you might think.

Nearly every country in Africa has recorded at least one case of Covid-19, leading over 30 nations on the continent to impose lockdowns to slow the spread. As of April 20, sub-Saharan Africa has more than 20,000 confirmed coronavirus cases and more than 1,000 confirmed deaths.

The lower numbers than other because African nations acted early to stop a wider outbreak, but also because there have been very few tests on the continent and a young population might not suffer as visibly as places like Europe. In other words, there may be a larger outbreak that just hasn’t been officially identified yet.

Either way, experts warn those low numbers are unlikely to last. Millions in Africa buy the food they eat on the day they eat it. Storing large amounts of sustenance just isn’t a viable option, which means the daily trip to the market is vital for many. Governments asking people to socially distance, then, likely won’t work in the long run.

A massive coronavirus crisis would “become quickly an equal food security crisis,” Sean Granville-Ross, a Kenya-based economic and agricultural expert at the humanitarian organization Mercy Corps, told me. “We know millions of people in Africa live just on or just above the poverty line. With the slightest shock or crisis, it knocks them below the poverty line.”

That will only exacerbate the known challenges Africa has. Many countries’ health care systems are ill-equipped to treat patients without support from international organizations. Many governments don’t have enough resources to tell citizens what precautions they should take to stave off the virus, such as washing their hands for 20 seconds or keeping 6 feet apart. And millions on the continent, mainly in the east and south, already suffer from other complications such as HIV/AIDS that could make them more vulnerable to a Covid-19 infection.

These and other concerns led the World Health Organization (WHO) to estimate the continent could see 10 million cases of coronavirus within the next six months. And a report last week from Imperial College London predicted that some 300,000 people on the continent might die from the disease. A separate report from the UN Economic Commission for Africa said that in the worst-case scenario with no interventions against the disease, more than 1 billion — that’s with a “b” — might get infected and 3.3 million could die.

Nipah Dennis/AFP via Getty Images

That’s a lot of bad news, but there are some reasons for optimism: Africa is an extremely young continent: More than 98 percent of the population is under the age of 65. That could make for a lower death toll than in places like Europe where the population skews older.

Many African nations also have experience dealing with major disease outbreaks, especially the 2014 Ebola crisis in West Africa. And international organizations are working to provide assistance and training.

Still, the continent’s larger problems like widespread poverty, poor governance, and major debt burdens mean the coronavirus crisis will likely deepen Africa’s woes for the foreseeable future.

“I’m worried for at least the next year,” said Michelle Gavin, the US ambassador to Botswana from 2011 to 2014.

Most African countries acted quickly to stop a larger spread

On February 3 — weeks before the novel coronavirus hit the continent — the Africa Centers for Disease Control and Prevention formed a task force to combat the virus. “This disease is a serious threat to the social dynamics, economic growth, and security of Africa,” Dr. John Nkengasong, the Africa CDC’s director, said at the time. “If we do not detect and contain disease outbreaks early, we cannot achieve our developmental goals.”

The organization’s main goal was to ramp up detection through testing and containment, especially at borders. Many African countries already had experience establishing similar checkpoints for diseases like Ebola.

Sub-Saharan Africa, then, had a head start in some ways before the continent’s first case was detected on February 27 in Nigeria. But there was a complication: The first case was an infected yet asymptomatic Italian man who’d traveled to the country and roamed freely for two days before his case was detected. Luckily, as the WHO African Region office’s technical director Dr. Mary Stephen told me, physicians in Nigeria were able to trace the man’s 121 contacts and found that only one person tested positive for Covid-19.

Other countries acted quickly once the first case in Nigeria was confirmed. Countries like Zimbabwe, Ghana, and Nigeria banned large public gatherings, closed schools, and imposed major lockdowns. In mid-March, some nations, like Sudan, also shut their borders to travelers from Europe, China, and the US to keep travelers from the world’s coronavirus hot spots away. In effect, it only took a couple of weeks — not months — to see a continent-wide response to the coronavirus.

Jekesai Njikizana/AFP via Getty Images

That response wasn’t uniform across the continent, though, and in some places it was disastrous.

In Kenya, for example, the government initially imposed a curfew, not a lockdown, to stop the virus’s spread. Experts say the curfew, which the Washington Post reports “requires people to stay in their homes from dusk to dawn,” wasn’t enacted thoughtfully, as it was hard for many workers to return home before the curfew. Police also brutally cracked down on violators, even killing teenagers. In late March, the death toll from police shootings related to the curfew outnumbered coronavirus deaths in the country.

In Tanzania, populist President John Magufuli also tried to minimize the coronavirus threat. In early April, Magufuli continued to tell his citizens to attend religious services because, he said, the only thing that could defeat the disease was divine assistance. “Coronavirus cannot survive in the body of Jesus Christ, it will burn,” Magufuli said last month. “That is exactly why I did not panic while taking the Holy Communion.”

But overall, the coronavirus denialism expressed by leaders from Brazil to Mexico to the United States to China may be less of an issue among those in power on the African continent. “Once you’ve seen the footage from Italy and New York City, it’s harder to convince yourself that someone’s making all this up,” said Gavin, the former US ambassador to Botswana who’s now at the Council on Foreign Relations think tank.

For some experts, those numbers are low not only because the virus arrived on the continent late, but also because African nations acted quickly and effectively. Other experts, though, note testing and tracking isn’t widespread, meaning the real infection numbers are probably much higher.

Starting this week, the Africa CDC will dole out 1 million tests across the continent. That’s a start, but even Director Nkengasong noted that 15 million tests may be required over the next three months for the continent of over 1 billion people. Part of the reason for the massive testing gap is that richer countries have outbid poorer ones for critical supplies.

Still, Africa’s swift response may have just been enough to avert the worst. While results have differed around the world, countries that acted fast typically have fewer confirmed coronavirus cases, fewer deaths, or both.

What really worries experts, though, are the bigger structural issues impacting Africa — weak governments, food insecurity, and poor health care — that could endanger all the good work already done to stop the coronavirus from ravaging the continent.

“I don’t know what ‘flattening the curve’ really means in this part of the world”

During major public health crises, governments typically step in to help their citizens stay on their feet. That’s not a given in many African countries. Only a handful of governments in Africa, including South Africa and Rwanda, even have the resources to patrol the streets or disseminate accurate health information to the public, let alone to provide an emergency social safety net for vulnerable individuals impacted economically.

And even if a government wanted to commit more resources to fighting the coronavirus or bolstering their economies during the crisis, most owe large debts to the United States, China, or European countries.

It’s no surprise, then, that leaders in sub-Saharan Africa are pushing for large-scale debt relief as one of the best ways to combat the disease. The G-20 — a group of countries representing the world’s 20 wealthiest economies — have already “agreed to freeze bilateral government loan repayments for low-income countries until the end of the year,” the Financial Times reports.

Brenton Geach/Gallo Images via Getty Images

But Ngozi Okonjo-Iweala, a special envoy from the African Union, isn’t satisfied. “My belief is that until the end of this year will not be adequate. We need a two-year time scale,” she told Politico last week. “I think that is what will give African countries the breathing room to be able to deal with the enormous consequences of the pandemic.”

China, one of the continent’s largest creditors, is balking at the idea of large-scale debt relief out of fear it might set a bad precedent of debt forgiveness. According to the Wall Street Journal, Chinese officials have asked officials from at least one country, Zambia, to provide collateral in exchange for help from Beijing — in this case, Zambian copper-mining assets.

Without large-scale and long-term debt relief, experts say, there is little chance most African governments will be able to effectively combat the disease or its economic impacts.

Other economic concerns, mainly the slowing of trade and loss of jobs, will surely make poverty and hunger in Africa more rampant.

Brian Bogart, who works at the UN World Food Program in South Africa, said that the world’s food distribution system will be impacted by the global economic slowdown. Food producers will struggle to gain access to credit and the supply chains required to grow crops and send them to market. Even simple items like chemical fertilizer to help plants grow in dry soil will be harder to come by.

At a more granular level, the loss of employment will make the need for food even more critical. That, in turn, will make social distancing measures harder to maintain. More than 1 million people are already out of work in Ethiopia, for example, and the continent’s GDP is expected to drop sharply this year.

Any day not making money, then, means fewer resources to buy food. That’s more devastating than it sounds, as Mercy Corps’s Granville-Ross told me the impoverished typically purchase food on the day they consume it. They don’t have the resources or ability to store large amounts of food for weeks on end. So while supermarkets remained stocked, items are often too pricey or too large for the poor to shop there regularly.

Many people in Africa spend the majority of their income on food. (For comparison, in 2018, Americans spent an average of 9.7 percent of disposable personal income on food, according to the US Department of Agriculture.)

This is a major concern. About a fifth of all people in Africa — about 250 million — didn’t have reliable access to food even before the coronavirus hit, while 25 percent of people in sub-Saharan Africa are already undernourished.

And so chaotic scenes of people fighting for food, like the one in the Nairobi slum of Kibera last week, become more commonplace. Meanwhile, agricultural producers are contending not only with the challenges of the coronavirus but also with locust infestations that decimate crops and rangeland. (Experts say an expected second wave of locusts could be 20 times larger than the first two months ago.)

All of this means that for millions in Africa, staying home from work for a few days to avoid spreading or contracting the coronavirus just isn’t an option. “Poor people will prefer the lottery of infection over the certainty of starvation,” African health experts Alex de Waal and Paul Richards wrote for the BBC last week.

Water, too, costs money. Washing one’s hands for 20 seconds with soap, then, becomes harder to do when a family has to weigh nourishment against sanitation, says Granville-Ross. These stresses are particularly acute in countries like Niger or Angola.

Nicolas Réméné/AFP via Getty Images

“There’s just no way to socially distance,” the Council on Foreign Relations’s Gavin told me, leading her to believe “there can’t be just one public health playbook for this crisis.”

Finally, the continent’s ability to care for the sick isn’t well developed.

“Most of the countries have at least one treatment center, but they range from some with less than 10 beds to some of them with 100 beds,” Michel Yao, the emergency operations manager for Africa at the World Health Organization, told France’s RFI in March.

A March report from the WHO looked at how prepared countries in Africa would be to deal with a coronavirus outbreak. The chart below shows that while some African nations had “adequate” readiness status to deal with an influx of coronavirus cases, the majority at best were at the “moderate” status.

That same report also cited other problems, including that just over half of the countries surveyed had readily available personal protection equipment (PPE) for health care workers.

World Health Organization

“I don’t know what ‘flattening the curve’ really means in this part of the world,” Bogart told me, “simply because there is not necessarily the same level of health care services or infrastructure to even overwhelm.”

But Stephen from the WHO’s Africa office and based in the Democratic Republic of the Congo expressed optimism that the provisions of health care will improve in the weeks ahead. Before the crisis, there were only two labs on the continent that could be used for coronavirus testing, she told me. Now, there are 44.

And the “integrated disease surveillance” system in place since 1988 — which allows local community members to let health authorities know if someone is sick — continues to work well.

After a community volunteer informs health officials, a team of epidemiologists goes to the house and asks if anyone feels ill. They’ll also go to nearby homes just in case “because some people are always hiding,” Stephen said. If the person’s symptoms match those expected from a coronavirus infection, then the physicians will ask for that person’s contacts even before the test results come back.

This is the same strategy African health care workers used during the Ebola outbreak, Stephen noted. The continent’s experience with that crisis has prepared physicians and others for what’s likely to come next. “Any experience with any outbreak is valuable experience for combating Covid-19,” she continued.

Nipah Dennis/AFP via Getty Images

It also helps that less than 2 percent of Africa’s population is over the age of 65. Which means that a high coronavirus death rate among the most vulnerable population — older adults — may not be the biggest fear.

All that said, Stephen is still aware of the major challenge ahead. “There is really, really limited capacity in their infrastructure for the management of severe cases,” she told me, adding that the lack of ICU beds and ventilators poses the biggest problem.

The continent’s good work getting ahead of the crisis, then, may have saved many lives. But Africa’s bigger problems mean that many more remain at risk. The hope is that the worst scenarios for Africa — hundreds of thousands dead and maybe even a billion infected — don’t come to pass.

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