Newsletter June 2020: Factors that may explain why COVID is less deadly in Africa

Dr. Antonio Villalonga Morales



I am a Spanish anaesthesiologist, who has lived in Kinshasa (DR Congo) since June 2019, and I work at the Monkole Hospital. Several friends have asked why in Africa there are far fewer cases of sickness and apparent lower risk of death from coronavirus. The answers to these questions have no known scientific evidence yet, but I believe there are several factors that may be involved.

The different behaviour of the COVID-19 pandemic in Europe and Africa is so far clear and striking. Deaths in the United Kingdom, Italy, France and Spain exceed 20,000 cases in each of these countries, while in African countries, such as DR Congo, they have counted 34 cases and in many other neighbouring countries, the data are similar. In my opinion, there are four factors that could explain these differences:

  1. There is a notable difference in the population age pyramids of the European and African countries. See below the example on both continents: France and the DR of Congo. Figure 1 shows that of those killed by Covid-19 in France, only 7.3% of the total deaths are under the age of 65. In other words, the virus has much less lethal effect on the young population and precisely 97.1% of the Congolese population is under the age of 65. To the contrary, only 2.9% of the Congolese are over the age of 65 years of age, while represents a large population in France reaching 19.1%. Indeed, the population age is a very important factor in the behaviour of the pandemic, but it is not known why the viral infection is mild in children and young adults but moderate to severe in the elderly. Nevertheless, the population age difference does not fully explain the less fatal course of the coronavirus in Africa since, by extrapolating the European data, there should have been many more sick and dead cases in Africa than there actually are. Figure 1.
  2. Environmental temperature. In Europe temperatures in the months of February to April are relatively cold. In Paris they have ranged from a maximum of 21 ° C to minimum of 1 ° C, while in Kinshasa they have varied from 34 ° C to 23 ° C. It remains to be proven, but it could be that the virus does not survive and/or spread as much in hot weather.
  3. Immune modulation. I feel that there must be another factor affecting the inhabitants of tropical Africa that makes them less vulnerable to the coronavirus than the European or North American counterparts. Note that the African-American population in the US is being especially affected by COVID-19. Therefore, it is unlikely to be genetic, but more likely related to the environment. It occurs to me that it could be related to malaria that practically affects almost all the countries and inhabitants of tropical Africa. To exemplify this in our hospital, we attend almost every day a hospital health worker affected by malaria. Malaria and perhaps its treatment may modulate the immune system; as a result, the stormy inflammatory response, that is the main cause of death in Covid-19, does not occur or gets ameliorated. All this is a hypothesis that should encourage further investigation.
  4. Social and political factors. The social and political factors are also very important, but I suspect, they have less weight here in Africa than in Europe. The majority of cases and deaths in Congo are concentrated in the wealthy neighbourhoods of Kinshasa, mainly in Congolese returning from Europe. By closing the country borders, the capital from the rest of the country and confining Gombe, the most affected neighbourhood of Kinshasa, from the rest of the city, the pandemic has slowed down. Whereas there was an early order to confine the population of the capital, it had to be revoked the following day given the impossibility to comply with such order by the majority of the population (a large proportion of the inhabitants, need to work every day to earn a living and houses are tiny without water or electricity). Even more, compliance with basic preventive measures, such as keeping the distance of more than a meter, avoiding crowds, washing hands and wearing a mask, leaves much to be desired. This week, I walked several kilometres from the exit route from Kinshasa to the Lower Congo. I passed markets in Matadi Kibala located on both sides of the road, where retailers, shoppers and distributors gather on the sidewalks, over the ditches that are full of waste. During the journey, in which there was great traffic congestion, people had to make their way among thousands, who come and go across small holding retailers with little product spread at their feet, waiting for buyers. In this continuous contact, only half of the people are wearing facemasks, and of these, less than half wear them appropriately. These local conditions would favour the expansion of the pandemic. However, the fact that this does not occur as much, makes me think that the described first three factors have a considerable influence that compensates for the deficiency in compliance with the required measures to prevent the expansion of the pandemic.

Let us hope that the pandemic in Africa continues like this, limited to a few cases and limited deaths. A scenario here in Africa, like the one that has occurred in Europe, would be “Dantesque”. In Europe, health systems have responded to the greater needs caused by the pandemic. Thus, to the generally adequate initial resources, extraordinary ones have been added; as in the case of critically ill beds that have multiplied by three or four in some countries. The vast majority of African countries have very scarce health systems that do not meet basic health needs. In general, it can be said that “without money, there is no medicine” and the norm is poverty. In DR Congo it is estimated that there are less than 100 ventilators, almost all in the capital. It is clear that many more are needed, but also specialised personnel, doctors and nurses, who know how to use them correctly. In short, it would be necessary to deploy a great international collaboration to minimally face an epidemic of the magnitude of the coronavirus in Europe and the USA.


Report from: Matadi Kibala (Kinshasa) in the last week of April 2020


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