Downgrading Sexual and Reproductive Health and Rights

COVID-19 has shown once again the urgent need to push for stronger and inclusive health systems in all African countries. As the novel coronavirus pandemic evolved (with an estimated 4.5 million of people testing positive for the virus in Africa) and new variants emerging, the pre-existing shortcomings in the African healthcare systems became more evident. While long-term impact is yet to be determined, these gaps along with a lack of investment in enabling environments (such as human rights) and unreadiness of many African governments to contain and respond effectively to the outbreak, had already a negative impact on many people’s lives. Pre-existing weaknesses in health systems and a lack to effectively address them have caused many ripple effects across health services, development, and human rights. One consequence resulting from African governments’ responses to COVID-19 is that of having restricted and even stopped access to sexual and reproductive services and related-commodities[1]; thus, having an adverse impact on people, including people who are LGBTIQGNC. Examples of areas impacted during COVID-19 include but are not limited to the following: restricted access to sexual and reproductive health rights (SRHR) information; to health services such as access to abortion, to gender affirming healthcare or to reproductive, maternal, newborn, child and adolescent health (RMNCAH) services, to early diagnosis and treatment for breast and cervical cancer, to prevention and treatment of reproductive tract infections and sexually transmitted infections (STIs) including HIV/AIDS; or to SRHR related commodities such as contraception or condoms.

The foremost commitment on SRHR in Africa is the Maputo Plan of Action (MPoA), i.e.: Continental Policy Framework on Sexual and Reproductive Health and Rights. In which governments commit to achieving universal SRHR in Africa by 2015 (now 2030), while the Maputo Protocol (MP) is the leading document that promotes and protects gender equality[2]. The MP provisions relate to bodily autonomy, determination and the right to abortion. While this is the case, the closure, and limitations of public health care in Africa to focus on managing COVID-19 are (to a certain extent) hindering the intentions of the MP and theMPoA[3] to protect and promote SRHR in Africa. The African Union’s Maputo Protocol on the Rights of Women came into effect in 2005 and has been signed by all African countries except Egypt, Morocco, and Botswana; It officially committed signatories to ensuring that reproductive health and rights of women and girls are protected, and it specifically promoted the right to SRHR in Africa, its implementation as well as the Agenda 2063[4] showing the commitment that have been made and the steps that ought to be taken by leaders to make them possible. 

Despite the progress that is made on paper by governments on these vital policies, Africa still has some of the most regressive and restrictive laws relating to SRHR and many people such as adolescents, LGBTIQ people, or persons who use drugs, or are sex workers – are left behind and cannot partially or fully access the SRHR they need. Some of these laws are strict and criminalize abortions with limited exceptions, lack of comprehensive sexuality education, restricted access to contraception by many people, including but not limited to trans people, adolescents, queer, gay and lesbian people, sex workers, girls and women and many more vulnerable persons and groups. SRHR is a human right, and in many cases, denied access to this right and services results in devastating consequences and even death. Although maternal mortality[5] , morbidity and cervical cancer[6] are a leading cause of death for women and girls in Africa, in many cases, government policy and healthcare systems are excluding intersex, trans and queer persons who are susceptible to the same risks.

UNAIDS has warned in the context of COVID-19 that “Adolescent girls and young women may be increasingly susceptible to violence, child and early marriage, and trafficking amidst school closures, coupled with lack of access to comprehensive sexuality education, contraception and abortion, as has been the experience during Ebola outbreaks and other public health crises.”[i] It also noted that the Convention on the Elimination of all Forms of Discrimination Against Women (CEDAW) Committee called on states to ensure “confidential access to sexual and reproductive health information and services such as modern forms of contraception, safe abortion and post-abortion services and full consent must be ensured to women and girls at all times, through toll-free hotlines and easy-to-access procedures such as online prescriptions, if necessary free of charge.”[7]

Marginalized communities are evidently affected more than other communities. The already existing multiple discriminations and marginalization faced by many people (including but not limited to LGBTIQ people, persons with disabilities, persons with albinism, persons who use drugs, migrants, refugees, persons who are currently in detention centers, etc.) are further exacerbated by a lack of access to SRHR services and accurate information. More so, movement restrictions under COVID-19 in terms of lockdown, curfew or distance that one is permitted to travel are posing further SRHR-related challenges. For instance, UN Women noted that “due to movement restrictions and declining incomes the ability of women who are sex workers to negotiate for the use of condoms has declined,”[8] while ASWA’s study shows further SRHR connections in terms of STIs including HIV transmission and unplanned pregnancies resulting from unprotected sex in context of sex workers in Africa.[9]

Abortion

Accountability International’s Scorecard for Women and Girls’ SRHR in Africa 2018[10] rates only five countries i.e.: Cape Verde, Mozambique, South Africa, Tunisia, and Zambia as scoring an “A” in terms of abortion policies giving unrestricted access to abortion, while 11 countries i.e.: Angola, Central African Republic, Congo, Democratic Republic of Congo, Egypt, Gabon, Guinea-Bissau, Madagascar, Mauritania, São Tomé and Príncipe, and Senegal prohibit abortion altogether. For women and girls in the prohibitionist countries there are no alternatives for them to get any assistance thus leading to unwanted pregnancies, early-school leaving, or even death. The restrictions of travel and the shutdowns have denied those who would have travelled to other countries to undergo abortions.

The impact of being denied access to abortion can be devastating for many people and can result in many health problems apart from unsafe abortion complications such as haemorrhage, infections, perforations or even death. Similarly, restrictions and limited access to purchase abortion tablets which can be self-administered are negatively impacting many people, including LGBTIQ persons. It must be stressed that the criminalization of abortion and the penalizing of its advocates and practitioners – as well as girls, women, trans boys and men who seek termination of their pregnancies – has not in fact curbed the practice of abortion but has driven it underground into conditions that are often unhygienic and is sometimes resulting in deaths, sterility, illness, long-term physical damage.[11] In many ways the response to COVID-19 has heightened the deliberate ignorance and shelving of the needed change of abortion legislation in countries in which abortion had already been restricted, conditioned by specific factors or altogether prohibited by law. Also, in contexts where access to abortion in unrestricted such as in South Africa, “providers of abortion and contraception have been forced to reduce or suspend their services” due to the pandemic[12].

Comprehensive Sexuality Education (CSE)

In terms of CSE, bodily autonomy teaches that a person is empowered to make their own informed decisions regarding their bodies, that they have access to adequate and accurate information on their SRHR, and have affordable, available, acceptable, accessible, quality (AAAQ) access to SRHR services.  The UNESCO/UNFPA East and Southern Africa Commitment on CSE (ESA) provides that CSE be inclusive, youth friendly and accessible. However, CSE in African schools seldom includes any scientifically based information on abortion rights. Teenage pregnancy is high in Africa with many young people having unmet contraception needs as a result of many factors, some of them being lack of youth friendly services, poverty, lack of access to health centers, lack of knowledge on use of contraceptives, etc.[13]

In a comparative study undertaken in 2020, the data showed that Chad  had a first teen pregnancy prevalence of 76.1% and Congo, 44,3%.[14] According to UNICEF data, Central African Republic, Niger, Mali and Angola also have high teenage pregnancy rates with over 178  per 1000 girls in the 15-19 age group.[15] It is critical that all persons (such as women, girls, trans diverse individuals, queer people, gender non-conforming persons, but not limited to these) must be able to access CSE and SRHR without discrimination.

Due to the lack of CSE including information and education on HIV and STIs prevention, many people are exposed to other health related risks such as contracting STIs, including HIV, Hepatitis and HPV (which causes cancer). In part, lack of CSE and access to adequate and age-appropriate information, for instance can result in low levels of condom use, misinformation and myths about what constitutes consensual sex.

Access to contraception

Access to contraception Africa has been found to be depending on the proximity to health care, marriage, age, level of education, sexual orientation, and other factors. According to ICPD 2019 health data, the modern contraceptives (CPs) prevalence for women ages 15-49 in Africa is as low as 7 % in Chad and South Sudan, 9 % in Guinea[16]. Although there are many CPs options available such as oral contraceptive pill, injectables, and implants, allowing thus individual choices on best and preferred options,[17] they are not provided by government and so for many people the costs are extremely high. Not only that health disparities based on income are leaving people behind, but also the provision of SRHR services and information that is based on heteronormativity are excluding many people including LGBTI persons[18].

Furthermore, the impact of the closure of schools, universities and colleges on access to SRHR as a result of COVID-19 protocols has led to compromising the SRHR services that students previously accessed in their school facilities. School and university programmes afforded students a privacy and confidentiality that is lacking when they are home and, in their communities. For instance, UNESCO estimates that millions of girls will not return to schools as result of unwanted pregnancies during COVID-19[19] which will have a long-life impact on their lives.

A UNFPA and Avenir Health analysis conducted in January 2021 on 115 low- and middle-income countries estimating the impact of COVID-19 on family planning noted that: “An estimated 12 million women may have been unable to access family planning services because of the COVID-19 pandemic, with disruption of supplies and services lasting an average of 3.6 months. This number could be as high as 23 million on the higher end of projections, or as low as 4 million at the lower end of projections. As a result of these disruptions, as many as 1.4 million unintended pregnancies may have occurred before women were able to resume use of family planning services. This number could be as high as 2.7 million at the higher end of projections, or as low as 500,000 at the lower end of projections”[20]

Direct effect of the Expanded Mexico City Policy (EMCP) in Africa

According to the University of Columbia and the NGO Change some of the key findings from their research are.

• Caused the total collapse of SRHR services, particularly in the remote regions of some African countries.
• Lead to a critical loss of community health workers (CHWs) with a resultant undermining of entire frontline healthcare systems.
• Distorted recipient countries’ general public SRHR messaging and healthcare advocacy.
• Lost many country programs the skills of the most qualified specialist healthcare service providers – even in areas not related to abortion like cervical cancer testing.
• Generated such confusion among SRHR non-profit organizations that many even refused abortion-related services that were allowed under the EMCP; and
• Caused such a funding crisis that some countries’ NGO sectors have not recovered.[21]

The US Government Accountability Office (GAO) (an NGO that provides data-based analysis for the US Congress and other bodies), had found that the US government had awarded about 1,300 health-care grants over May 2017 (when the GGR came into effect) and 30 September 2018, the end of that financial year, comprising about US$12 billion in planned funding that was not “obligated” (that is, allocated for a specific timeframe) by the end of that period. Of this, about 96% of this funding was provided by USAID and the Center for Disease Control (CDC) – roughly split between them – and by region, about US$8 billion was for projects in Africa, with all of the top ten recipient countries being in Sub-Saharan Africa. The effects of the EMCP have led to some closure of organizations as result of lack of funding as shown below leading to many not to access SRHR services. These organizations were offering reproductive health information and pregnancy counselling; information on legal abortion services; contraception provision, counselling or referrals; HIV counselling and testing and adherence support; cervical cancer screening; condom provision; youth outreach – to name a few examples.

According to the WHO Regional Office for Africa’s rapid assessment of continuity of SRHR services during COVID-19, fear and a lack on information meant many people did not access family planning and comprehensive abortion care. For instance, in 70.6 % countries (out of 17) “fear of patients/clients to seek SRHS at designated health facilities as they might contract COVID-19; while in 52.9 % lack of information on the continuity of SRHS as essential health services were the key challenges.[22] Other issues were lack of supportive supervision and lack of trained HCWs (in 41.2% countries), lack of trained HCWs, or lack of commodities (stock out) in 35.3 % countries.[23]

Conclusion

It is evident that access to timely and quality SRHR services and information has been immensely affected by the lack of an adequate and inclusive response from governments in strengthening healthcare systems in the past, and in responding effectively and inclusively to COVID-19 now. The disregard by African leaders for SRHR is a direct violation of the right to life. The burden that COVID has placed on health systems in Africa has only pointed out pre-existing shortcoming and gaps that have led to comprehensive SRHR care being neglected, ignored and will continue to have devastating effects on all people now and in the future if not adequately addressed. There is lack of inclusivity of all genders and people of diversity, key populations, vulnerable people including people living with disability. Access to SRHR services is vital and is lifesaving; access to SRHR is a basic human rights and African governments must treat it as such.

Recommendations

1. Introduction of inclusive CSE from primary school so that it is established at a young age the knowledge, rights, responsibilities, and information regarding CSE and SRHR. To have continuity during the global pandemic which has led closure of schools.

2. Capacitate hospitals with equipment and personnel that are key in providing quality and impartial services so that access to SRHR is enhanced and enjoyed by all. Improving and using medical technology to reach those in need of SRHR in hard-to-reach areas, rural places and for ease of reach and access during COVID-19 where hospitals and services providers are limited.

3. 3. Inclusion of the right to SRHR as a right in all national laws must be inclusive of women girls in all their gender diversities, men, trans boys queer people. Countries are encouraged to adhered to the provisions of the Maputo Protocol to CEDAW Protocols for countries that have acceded to them and eliminate all violence and Include SRH as a right in Constitutions, all the necessary laws and policies so that it is not neglected and for the rights holders to be able to claim their rights. Make effective public health laws and policies for ease and comprehensive access and a better quality of health and life.

6. Make SRHR a priority and essential service so that the tremendous effects that COVID-19 is having across the world is not adding to the already Multiple discrimination on key populations and LGBTI persons. Reproductive inequalities are deep and evident from women living with disabilities, rural, indigenous women and poor women. SRHR equity must be promoted and respected so that it also becomes part of gender equality, therefore leaving no one behind.

7. Reliable data is needed for LGBTI persons’ s access to SRHR services in Africa and all marginalized and vulnerable communities.

8. Decriminalize abortion. Even where abortion is restricted, abortion take places which many may be unsafe and lead to deaths, border abortion services take place. Restricted abortions impinge on the right to bodily autonomy, self-determination, and the right to choose. The continuous policing and degrading of women in all their gender diversities is rooted in patriarchy, which is also the direct effect of anti-abortion laws.

9. Awareness raising particularly at community level to shift mindsets and cultural connotations on the understanding of SRHR holistically. In addition, understanding of abortion and CSE will go a long way in the society accepting and having knowledge. Therefore, that will eliminate and reduce stigma and discrimination on those who seek abortion care and in cases of adolescents who engage in early sexual debuts.

10. Investment in SRHR so to not to reply on foreign aid as it is evidenced by the Gag Rule which left many African organizations in shambles, investment in HIV care and management, cancer diagnosis and treatment, TB. Comprehensive SRHR will contribute towards the right to the highest attainable health and a better quality of life.

11. Strengthening SRHR services and commitment to reduction of maternal mortality and morbidity, FGM, fistula amongst other maternal associated violations, illnesses, and disorders. The burden of COVID-19 had led to a shift in access to SRHR services.

12. Accountability; Leaders must be accountable for the SHRH commitments they have made at domestic and regional level. The ESA, Maputo Protocol, SADC Gender Protocol, Agenda 2063, Sustainable Development Goals, and CEDAW provisions must be effectively implemented so that the right to SRHR is a lived reality and all people in all diversities are not left behind.
13. Active role of the CSOs: The role of civil society is multifaceted, apart from holding leaders accountable, CSOs play a role in highlighting in bringing to the fore the gaps and challenges that needs to be addressed. CSOs provide technical know-how and advisory that should not be underestimated but used to promote and advocate for the realization of SRHR.

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Footnotes

[1] https://esaro.unfpa.org/en/news/studies-show-severe-toll-covid-19-sexual-and-reproductive-health-rights-around-world

[2] AIDS-Accountability-International-Scorecard-for-Women-and-Girls-on-SRHR-in-Africa-Report.pdf (aidsaccountability.org)

[3] https://au.int/sites/default/files/documents/24099-poa_5-_revised_clean.pdf

[4] https://au.int/agenda2063/goals

[5] Maternal mortality Key facts (who.int)

[6] Burt et al https://ascopubs.org/doi/pdf/10.1200/GO.20.00079

[7] Six Concrete Measures to Support Women and Girls in All Their Diversity in the Context of the COVID-19 Pandemic, UNAIDS, online at: https://www.unaids.org/sites/default/files/media_asset/women-girls-covid19_en.pdf

[8] Impact of COVID-19 on gender equality and women empowerment in East and Southern Africa.pdf (unwomen.org) P. xxiii

[9] ASWA STUDY ON VIOLENCE AGAINST SEX WORKERS IN AFRICA – ASWA (aswaalliance.org)

[10] https://online.fliphtml5.com/cwrmu/vchh/#p=1

[11] https://www.who.int/news-room/fact-sheets/detail/preventing-unsafe-abortion see also See https://www.guttmacher.org/fact-sheet/abortion-subsaharan-africa 

[12] Why abortion and contraception are essential healthcare | Amnesty International

[13] Ahinkorah et al Prevalence of first adolescent pregnancy and its associated factors in Sub Saharan Africa: A multi-country analysis, 1.

[14] Ibid,8

[15] https://data.unicef.org/topic/child-health/adolescent-health/

[16] Monitoring ICPD Goals: Health,

[17] Apanga PA et al Prevalence and factors associated with modern contraceptive use among women of reproductive age in 20 African countries: a large population-based study https://bmjopen.bmj.com/content/bmjopen/10/9/e041103.full.pdf

[18] Muller et al  The no-go zone: A qualitative study of access to sexual and reproductive health services for sexual and gender minority adolescents in Southern Africa https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-018-0462-2

[19] https://en.unesco.org/news/covid-19-school-closures-around-world-will-hit-girls-hardest

[20] COVID_Impact_FP_V5.pdf (unfpa.org)

[21] Prescribing Chaos (on Mozambique and Zimbabwe), and A Powerful Force (on Malawi)

[22] CONTINUITY OF ESSENTIAL SRHR SERVICES LEOrevised2.pdf (who.int)

[23] Ibid. P. 7

Sex, gender, and medical vulnerability of men under COVID-19

Since the beginning of the COVID-19 pandemic, scientists have warned that reliable data on the spread and evolution of the virus is not easy to come by, for various reasons. Considering that COVID-19 is an evolving novel virus, and the use of different data collection and analysis methodologies used by different countries and entities, it is even more difficult to find disaggregated that shows vulnerability and susceptibility based on gender. Well researched areas are the effects of sexually transmitted diseases on gender, but research remains limited in terms of epidemics.[1] The reasons may be ascribed to, for instance, the use of different methods of data collection that may have shortcomings, or a lack of inclusion of specific data points, data interpretation, lack of geographical information, gender diversity and inclusion – these are but a few examples. Additionally, small data samples can lead to inconclusive or even misleading information, whilst some research methodologies are limited in scope and are very situation specific.

Most countries are either not collecting or not making available data broken down by sex, gender, age, and other characteristics, such as class, race, location, and migrant status.[2] This is especially so for African countries, where in general there is no COVID-19 available disaggregated data that is inclusive of sex, gender, sexual orientation, disability, economic status, geographical inequalities, or employment/unemployment status. This lack of data and gaps in our knowledge might have a direct negative impact on the response to the COVID-10 pandemic and in misshaping it, which may have dire and long-lasting consequences.

An estimated 3-million people have died globally from COVID-19 – for an estimated 107-million recoveries. The Africa Centre for Disease Control and Prevention (Africa CDC) provide that 115,765 deaths have occurred in Africa since the onset of the pandemic, with over 4.3-million positive cases and over 3.9-million recoveries and 41, 531, 494 tested people.[3] According to the COVID-19 Sex-Disaggregated Data Tracker, at global level available data shows that for every 10 female cases there are 10 male cases. However male individuals are more impacted in terms of other areas such as ICU admissions, that is for every 10 female admissions, there are 18 male admissions.[4] The number of COVID-19 positive confirmed individuals that have died that is, for every 10 female confirmed deaths, there are 15 male deaths.[5]In this regard, at global level WHO data on sex ratio for COVID-19 cases and deaths for 30 December 2019 to 1 March 2021 period shows that from an estimate of 61 million cases, confirmed and probable, 48,96 % of individuals affected are male whereas 51,04 % are female. Additionally, data from 991,467 deaths, confirmed and probable shows that more male deaths occur because of COVID-19 with 58,51 % male deaths compared to estimate of 41,49 % of female deaths.[6]

Biology, behaviour & environment

In treating diseases, sex and gender are considered in addressing the response. While there are no concrete scientific explanations why that is the case, preliminary studies suggest that there are possible behavioural and biological reasons and risk factors that make men more susceptible to COVID-19. Some of the possible biological contributing causes are smoking tobacco, hypertension, diabetes, cardiovascular diseases, weaker immune systems, testosterone, blood pressure, cancers with indirect and direct immune-suppression, chronic neurological disorders, HIV, TB and sickle cell disorders.[7] Behavioural reasons that have been pointed to that may contribute to this dynamic include, amongst others, poor male hygiene and as compared to women who more frequently wash their hands. This might be related with the fact that social construction of gender and gender roles, for instance, the burden of household management falls to women in all their gender diversities. Thus, this aspect is critical during COVID-19 as washing hands and wearing of masks is recommended to prevent COVDI-19 infection. A lack of physical activity and the eating of unhealthy foods are also attributable factors which may lead to men being highly susceptible to COVID-19, as compared to women.[8]

Other reasons relating to risk factors on genders are susceptibility, exposure, gender roles, access to health, knowledge of disease, immunization at a young age, geographic location in terms of well resourced and poor resources countries, and morbidity of either gender. Critically, the response to a disease by an individual can also be viewed from their perception of the seriousness of the disease, access to health facilities and adherence to health policies. In the case of COVID-19, adherence to protocols and access to health are some of the key factors for prevention.[9] For instance, 2 in 3 (66%) respondents surveyed in a ACDC study on COVID-19 vaccine perceptions indicated “having seen or heard at least some rumors about COVID-19, with 2-in-5 (42%) claiming to have been exposed to a lot of disinformation”. The report also noted that “men tend to mention that they have seen or heard a lot of disinformation (45% vs. 38% of women), whilst some women feel they have had no exposure at all.”[10]

In Africa, additional factors that must be investigated include nutrition, socio-economic status, poverty, and water, sanitation, and hygiene (WASH) – particularly the challenge of the poor accessibility of clean water and flush toilets across most of the continent. Over 65% of pit latrines are found in Sub-Saharan Africa;[11] this poses a danger to the high degree of personal hygiene required under the pandemic, as it may lead to sanitation-related diseases[12]  – as well as further spread contamination and infection by the novel Coronavirus. The economic status of people living on the bare necessities is also crucial to their ability to protect themselves in overcrowded slums from the pandemic. Sub-Saharan Africa has the highest number of HIV infections and TB, and the greater incidence of these diseases among men suggests another strongly interactive co-morbidity with COVID-19. With the newly-discovered variants of COVID-19 – which demonstrate the virus’ dangerous ability to mutate and evolve rapidly – it is even more necessary that currently disaggregated biological, behavioural, and environmental data should be included in the response to the pandemic. The outcomes of such reintegrated data regarding men in their gender diversities and women in their gender diversities should better inform countries of how to deal with the varying hygiene and healthcare needs of different population groups, and to respond to COVID-19 and the management of COVID-19 effectively. This will also provide an avenue for the improvement of future healthcare interventions to better respond to people’s needs effectively in health emergency and pandemics.

Sub-Saharan African case studies

It is apparent that comorbidities in this case must be thoroughly investigated so that the differences between men and women in their gender diversities can be used to focus on creating sustainable and effective responses. A key paper on the gender differential in COVID-19 mortality states: “Hypotheses based on risk factors that are known to change with both sex and age seem to be the most probable explanations for the differences observed. These include differences in occupation, lifestyle including smoking and alcohol use, medical comorbidities, or use of medications. These explanations reflect social and cultural factors related to gender rather than the biology of sex. Genetic explanations will need to consider the interaction of age, sex, and the risk factors previously mentioned through the life course, including gene expression and epigenetics,”[13] the last term meaning changes in how genes present themselves.

In December 2020, the Sex, Gender and COVID-19 Project run by the African Population and Health Research Centre (APHRC) in conjunction with the International Centre for Research on Women (ICRW) and Global Health 5050 stated that sex disaggregated data was only available for 6 African countries; Chad, Sudan, Gabon, Liberia, Zimbabwe, South Africa, and Malawi.[14] While globally COVID-19 sex-disaggregated data is also not being sufficiently reported, low resource economies like Africa are likely to suffer more in terms of people not being adequately assisted in accessing health services. Thus, the Partnership for Evidence-based COVID-19 Response (PERC), a coalition including the Africa CDC, stated, “many countries are not reporting epidemiological data often enough. Key indicators are not reported systematically across the region; these include new confirmed and probable cases and deaths (broken down by age and sex), percentage of positive tests, daily hospitalization rates, and diagnostic turnaround time. This makes it difficult to understand the contours of the outbreak in a specific country as well as across the region.”[15]

For instance, WHO COVID-19 cases and deaths with age and sex reported data for Africa, summarizing data for 30 December 2019 to 22 March 2021 period, shows that from 11, 941 COVID-19, confirmed and probable cases 61,34% are male whereas 38,66% are female across all age groups. Similarly, data on confirmed and probable data shows that from 724 deaths, 65.06% were male, compared to 34,94% female across all age groups.[16]However, this needs to be carefully assessed and interrogated considering the above challenges, specific national and local demographics, and the fact that the African continent has a population of estimated 1.3 billion people for which these estimates are not entirely reflective.  In a study conducted in 2020, which covered 8 countries including Italy, USA, Austria, and France showed that more women than men believed that COVID-19 was serious and agreed with the set protocols.[17]

A 10 September 2020 opinion piece on the Devex website, a global developmental community media platform, stated: “In sub-Saharan Africa, men account for over 60% of confirmed cases in most of the countries where data is available. South Africa, which accounts for half of the continent’s cases, is the single outlier, as women make up nearly 60% of confirmed cases, and the gap appears to be growing. In varied ways, gender, including gendered differences in pre existing health conditions, occupational exposure, uptake of protective behaviors, and access to testing is likely contributing to these disparities.”[18] The gap that exists in lack of disaggregated data in Africa, leaves out different diversities of men, for example transgender men, gay men, men who have sex with men, and bisexual men are not factored into the pandemic response. While that is the case, a US based research conducted by Centre for Control for Diseases and Prevention has shown that key and minority groups are affected by various co-morbidities that make them more vulnerable to COVID-19 than heterosexual individuals.[19]The challenges of accessing health services, or sexual and reproductive health services which are heterosexual-oriented and -focused already disregards the differentiated needs of men who identity differently from the normative sexual orientation, gender expression and identity (SOGIE). While the response to COVID-19 has burdened countries, there should be reliable data to show which specific population groups and communities are more affected and less affected. In particular, marginalized and criminalized groups need to be taken into account in order to adequately and accurately show where the greatest need for improvement lies, and where the benchmarking of real progress and inclusion can be done.  

The sources of information both at regional and country level are scarce in Africa. The Africa CDC had published daily country statistics on COVID-19 from April 2020, which was especially useful to researchers, donors, and policymakers in the early first wave of the pandemic. Yet in August 2020, as the second wave started to take effect, the Africa CDC’s daily data was discontinued in favour of irregular data reports every few days, so there is no source of continuous, clear, and reliable information on COVID-19 across Africa at country level. Many countries are not reporting epidemiological data often enough. Geographical, biological, behavioural, psychological, environmental, and social factors must be thoroughly investigated so that policymakers in government, the international donor community, and in healthcare understand what factors truly make men more susceptible to COVID-19 infection and death. The gender differences, perceptions and adherence to COVID-19 protocols may also provide information as to why men, in some contexts, are more susceptible to COVID-19 hence there is need to comprehensive data.[20]

Recommendations

1. Creating consistent reliable data. Poorly resourced countries must find cost-effective and innovative ways during and after the epidemic to be able to secure the data that is needed to properly track and manage the number of boys and men in all their diversity who are affected. There must be collaboration between national census and statistics offices, service providers, and civil society organizations to find innovative ways of getting the data that is needed. For example, cellphone messaging services and off-line apps could be used to collect data that can be segregated by researchers for gender and other variables. A concerted effort must be made on improving services and informing strategies that will benefit the health of men and boys in their gender diversities regarding their specific vulnerabilities during this pandemic.
2. Community involvement. Communities must be made an integral part of collecting data to supply to the appropriate authorities. Accountability International has demonstrated time and again that community-based service organizations know their environments best and are the ideal grassroots partners who should shape the policy, pharmaceutical and other interventions by governments and donors alike.
3. Funding and investment. Funders need to equip scientists with appropriate funds to be able to carry out the necessary research work and explore further avenues of investigation that can assist countries in getting the necessary segregated data so that African that countries are able to include a true assessment of the specific risks associated with men and boys (in all their SOGIE diversity), and so efficiently provide services without compromising their health even further.
4. Policy and law reform. African policymakers’ response to the pandemic will have long-term effects as it will also inform future responses for men in all their diversities medical needs post-pandemic in terms of healthcare systems’ general responses to the needs of male and boys in accessing healthcare and their specific biological, physical, and physiological medical needs. Such forward planning should improve healthcare services as they will be targeted and specific to the cohort of men in all their SOGIE diversity, and address the specific needs that they experience. The policy, governance, and economic progress of African countries will be greatly reliant on accurate, relevant, unbiased and complete data. Such data must be inclusive, transparent, accessible and disaggregated which is inclusive of all boys, men, as well as women and girls, and transgender and intersex persons in their own SOGIE diversities.
5. Disaggregated Data. It has become even more urgent that Africa has disaggregated data so that no one is left behind and that the response to COVID-19 among men their SOGIE diversity are specifically included in the response. Research methods like the Participatory Action Research (PAR) model must be used in research as it is community-centred and it yields comprehensive and accurate date that is led and verified by various communities, while fewer assumptions yet bigger data-samples can be made.

Conclusion

AI has demonstrated time and again that the lack of sound disaggregated data for vulnerable groups, such as persons with disabilities, older persons, indigenous peoples, migrants, and others, exacerbates their vulnerabilities by masking the extent of deprivation and disparities and making them invisible when designing policies and critical measures. The funding of research producing consistent and reliable data should lead to countries acting to close many of the inequalities that have been largely exposed by COVID-19. More so the inequalities that are felt and are lived experiences of vulnerable and key populations.  With the right data, adequate access to healthcare facilities and recovery care and management support systems can be achievable for the short term and long term for men in their diversities.

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Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

[1] GWH_Cover_final.indd (who.int) Accessed 12 April 2021.

[2] https://africacdc.org/covid-19/ Accessed 20 January 2021.

[3] https://africacdc.org/covid-19/ Accessed 12 April 2021.

[4] The COVID-19 Sex-Disaggregated Data Tracker | Global Health 50/50 Accessed 08 April 2021.

[5] Ibid.

[6] Microsoft Power BI WHO Data Accessed 08 April 2021.

[7] Ghisolfi S, et al. Predicted COVID-19 fatality rates based on age, sex, comorbidities, and health system capacity. BMJ Global Health 2020;5: e003094. doi:10.1136/ bmjgh-2020-003094 https://gh.bmj.com/content/bmjgh/5/9/e003094.full.pdf. Accessed 12 April 2021.

[8] Bulletin of the World Health Organization (who.int) 39. Accessed 12 April 2021.

[9] Ibid, 1 above,4.

[10] Africa CDC, COVID 19 Vaccine Perceptions: A 15 country study, COVID 19 Vaccine Perceptions: A 15 country study – Africa CDC P. 5, Accessed 29 March 2021.

[11] Kumwenda S et al Estimating the Health Risks Associated with the Use of Ecologically Sanitation Toilets in Malawi Journal of Environmental and Public Health Volume 2017 2  https://doi.org/10.1155/2017/3931802.

[12] Ibid.

[13] Griffith D et al Men and COVID-19: A Biopsychosocial Approach to Understanding Sex Difference in mortality and recommendations for Practice and Policy Interventions https://www.cdc.gov/pcd/issues/2020/20_0247.htm Accessed 20 January 2021.

[14]https://globalhealth5050.org/the-sex-gender-and-covid-19-project/ Accessed 20 January 2021.

[15]https://reliefweb.int/sites/reliefweb.int/files/resources/PERC_RespondingtoCovidData.pdf Accessed 11 February 2021.

[16] Microsoft Power BI WHO Data COVID-19 cases and deaths with age and sex reported data for Africa Accessed 12 April 2021.

[17] Galasso et al Gender differences in COVID-19 attitudes and behavior: Panel evidence from eight countries (pnas.org) Accessed 12 April 2021.

[18]https://www.devex.com/news/opinion-we-lack-an-essential-component-to-power-covid-19-response-98054 Accessed 16 December 2020.

[19] Heslin et al MMWR, Sexual Orientation Disparities in Risk Factors for Adverse COVID-19–Related Outcomes, by Race/Ethnicity — Behavioral Risk Factor Surveillance System, United States, 2017–2019 (cdc.gov) Accessed 12 April 2021.

[20] Galasso et al Gender differences in COVID-19 attitudes and behavior: Panel evidence from eight countries (pnas.org) Accessed 12 April 2021 27290 Accessed 12 April 2021.

The Impact of COVID-19 on Trans- and Gender-diverse Communities

COVID-19 has exposed throughout the world the deep inequalities that exists amongst people and this has affected vulnerable, key and marginalized communities more. This is because of the multi layered existing negative and regressive laws, policies and practices that outlaw, criminalize, police, and intimidate those communities.  COVID-19 led to restrictions that affected the mentioned communities.  The trans diverse communities have been adversely affected, left behind in the response to COVID-19. Lack of access to sexual and reproductive services, gender affirming health care, food relief and general access to services in the society has deepened the exclusions felt by trans diverse communities.

In 2016 Gender DynamiX engaged Accountability International to conduct qualitative situation analysis on the barriers that trans-diverse persons in Africa face in accessing healthcare, with specific focus on the intersections between legal and policy frameworks that create and maintain these barriers, for five countries in Southern Africa: Botswana, Swaziland (since renamed Eswatini), Zambia, and Zimbabwe. The research was done by trans-diverse organisations in each of the countries, and the report produced, Southern Africa Trans-Diverse Situational Analysis: Accountability to Reduce Barriers to Accessing Healthcare [1](available here) was the first-ever such regional analysis to be published on the region, which underlines the critical research and data gap in this field, further abroad in Africa.

Due to the lack of data on trans-diverse people in Africa and their situation regarding rights and heath access, the situational analysis required two questionnaires in order to gather the data required. One questionnaire was completed by country trans led organisations, and the second was completed by trans-diverse individuals in each country. The data covered the legal and policy environment, quantitative health-care data, gender-affirming healthcare, citizenship, law enforcement, and user-friendly services, while the data comprised trans experience survey. Our Scorecard of the grading of the four countries on the data – where a score of B means “significant progress”, D “slight loss of progress” and E “significant loss of progress” – follows:

Among the results of the survey, it was clear that access to healthcare was the most impeded right in the four countries because of gender-incongruent identity documents, as the following graph shows that:

Although the research was initially limited to six, and finally to four countries in only Southern Africa, its key findings and recommendations may to a significant extent be extrapolated to the rest of the continent.

Excepts from the Executive Summary on extreme Vulnerabilities experienced by Trans Diverse Communities

The executive summary[2] of the novel AI- Gender Dynamix study noted the backdrop against which the COVID-19 pandemic has subsequently affected trans communities: “The trans-diverse communities in the four countries studied, Botswana, Zambia, Zimbabwe, and Swaziland, represent a remarkable constellation of communities characterized by extreme vulnerability because of their intersectional location as among their countries’ most excluded – unemployed or criminalized, susceptible to disease and despair, targeted for sexual assault and hate crimes, and cut off from education, housing, health-care, sports and social activities, and to many basic benefits of citizenship and amenities of society. Yet trans-diverse people are possessed of remarkable strengths in terms of their survival skills and tenacity in overtly hostile environments where because of having to either face social erasure or are actively persecuted as a group that ‘should not’ exist.

“The power of trans-diverse agency should not be underestimated, as two remarkable examples will make clear: a) although many members of the trans community who answered this survey have experienced prejudice in, including expulsion from, their childhood homes, 38% of those surveyed started their own families; and b) although many trans-diverse persons experienced prejudice in, including expulsion from, school, fully 18% of those surveyed completed tertiary education – higher than the national average in at least three of the countries surveyed. However, a total policy vacuum regarding the existence, nature and needs of the trans-diverse community mars all the countries studied. This invisibility not only allows for blanket ignorance to reign among officialdom and the broader populace, on the one hand disabling trans persons’ ability to access ordinary (and specialized) health- care and legal remedies, while on the other hand enabling casually vicious discrimination up to and including violent hate crimes and police home invasions (the latter experience restricted to Zambia [in this study]). Even the protections that the trans-diverse supposedly possess under constitutional equality/human rights legislation appears to fall away in most real-life circumstances.

“There appears from the study to be a simple and brutal equation to this prejudicial exclusion (note: as the paragraph on agency above demonstrates, this does not apply to all trans-diverse people, but is a very common experience):

• Lacking identity documentation aligned to their preferred gender, trans-diverse persons experience extreme discrimination at school, at church, and in other social settings at the hands of their peers who are ignorant of and uncomfortable with their gender identity;
• Facing active discrimination from family and church leaders – who are likely to sexually molest many trans-diverse people – their experience finally drives trans-diverse people out of school before completion of their studies, and also out of home (another key site of sexual abuse);
• Trans-diverse people are at a permanent disadvantage against former peers in seeking work in that they are underage, underqualified, can’t progress further in their studies, and cannot secure basic documents such as a driver’s license (a significant minority of those few that manage to secure work are likely to experience sexual harassment at work, or to lose their jobs as a result of their gender identity) so most of them wind up unemployed.
• Lack of education, employment, plus official and societal discrimination against the trans-diverse usually means they cannot access housing and wind up on the street, which drives them into underground subsistence activities including petty criminality and especially sex-work in order to survive;
• That demi-monde existence in turn makes them even more vulnerable to abuse by members of the public and the police (including arbitrary assault, arrest, and detention), to substance abuse and self-harming behaviour including suicide attempts, and to disease including but not limited to STIs [sexually-transmitted infections], HIV/Aids, TB and viral hepatitis; so
• Ill and in desperate need of medical attention and psychological assistance (not to mention hard-to-get hormones and almost unreachable transitional surgery), the trans-diverse turn to the health-care system – but encounter yet more ignorance, prejudice and even abuse.”

Lockdowns & Livelihoods

Considering the Coronavirus pandemic, governments across Africa enforced nation-wide lockdowns, movement restrictions and curfews as a measure to protect and save millions of people from infection While the lockdowns were a necessary measure to save lives, it had a considerable impact on people’s daily livelihoods.

The transgender community was not spared from the adverse effects of the lockdowns, especially the transgender populations that live in rural and remote areas of Africa who are isolated and not included in the response to COVID-19. [3]Many transgender people in rural and remote areas do not have a stable income. Instead, they rely on piece-work, mostly in the informal economy, to sustain their livelihoods. The nature of such work means that most transgender people live on a hand-to-mouth basis. Due to the strict lockdown regulations prohibiting all work that is not regarded as an essential service, transgender populations were for months without any form of income. Consequently, this has threatened their food security and livelihoods.

Although there were other pressing needs, such as the lack of access to gender-affirming health-care services that most activist fought for – physical, emotional, sexual, and psychological abuse amongst others – most organizations had decided to prioritize the issue of food security and mental wellbeing.[4]  It must be noted that some dire consequences experienced by trans diverse persons are lack of access to Gender Affirming Health Care (GAHC) particularly in countries like South Africa where GAHC is accessible by virtue of that upon lockdowns non-citizen trans diverse persons had to travel to their own countries. Mental health was a priority for most trans diverse communities movements across Africa as the isolation in homes with family members or partners that were abusive due to either lack of acceptance within the home.[5] or Intimate partner violence, was at an all-time high, and many cases of IPV went unreported to authorities. Some had mostly been with dealt with by peer educators from trans diverse organisations to support persons particularly who are unable to report.

Most countries went through heavy militarization and this severely affected the trans diverse communities freedom of movement, while also exposing most trans- and gender-diverse persons to violence from the police mainly because their national documents that were required when moving around performing critical tasks such as securing food, did not match their gender identity. Trans movement-building was also affected as most donors reprogrammed their funding for COVID-19 responses, and this meant a lot of the already under-funded trans and gender diverse organizations lost a lot of staff members, which in turn also reduced the number of members that they could reach and therefore made their communities more vulnerable.

Trans Diverse Community Responses, Achievements & Challenges

To respond to these pressing needs, most trans diverse organizations decided to repurpose some parts of their grants to finance emergency food distribution for trans diverse communities and mental wellbeing support services, the latter mostly delivered telephonically. There was continued advocacy against police brutality and access to gender-affirming healthcare, countries with access to gender marker changes continued advocacy on how important it was for people to continue accessing this service as it remains a fundamental right.

The trans movement’s greatest success was being able to support their constituencies with food security. Most organizations in this period were also able to strengthen their response to mental well-being issues. The continent lost a lot of its core funding for trans* organizations, campaigns, and projects – and remains severely under-funded. The reprogramming by donors has severely crippled the movement and its activities. Particularly hard-hit are nascent and upcoming organizations. Adding to these stresses are the continued stigma and discrimination directed at trans- and gender-diverse communities by the institutions of religion and traditional authorities.

Recommendations

 The study shows clearly that the state’s ignorance leads to a lack of progressive policies and the lack of gender-appropriate identification in order to access services, especially health-care – while societal ignorance leads to widespread discrimination, abuse and hate crimes against trans diverse people.[6] There is an urgent need in all African countries to fill in the policy gap, starting with an extension of the key populations interventions to include trans-diverse communities, and  by so doing so enable the legal recognition and human rights protection of those communities. This starts with the legal recognition of trans diverse communities identities.

The report’s recommendations below and please note that although these were derived from only four African countries, the issues canvassed are universal and so the recommendations readily apply and are at least adaptable to countries in the continent:

1. Recognition and Inclusion of Trans diverse communities: This legislative reform needs to be allied with a pro-active educational campaign among health-care professionals, police and magistrates, judges, church, religious leaders, and the broader society. Further policy reforms should involve enabling non-prejudicial access to healthcare, psychological support, transitional hormones and surgery, and other elements necessary for the restoration of the communities to the mainstream of the population – integrate into the general COVID-19 pandemic response – albeit with specialised concerns. The dismantling of official exclusion and invisibility and of official prejudice and abuse should mark the start inclusion of the trans-diverse communities from the underworld of their societies to full, normal, and active citizenship.

2. Trans Community Foregrounding: The trans diverse community visibility that comes with an associated vulnerability the community must use their own collective agency where there is no direct danger – especially regarding consultations on all matters affecting them. Their specificity in relation to the LGB and cis-normative communities must be recognized in a non-prejudicial manner, as must identity and desired outcome differentiations within their community.

3. Availability of Data: Better quality data needs to be collected on trans diverse people’s access to health, education, employment, issues of stigma and violence, amongst many other issues. Programming without data could be wasteful of the ridiculously resources available to the trans movement at this time. Bodies such as the United Nations and the African Union Commission need to lead on collecting inclusive and disaggregated data and making it an imperative at all levels and in all spaces.

4. Policy Reforms: Given that the policy vacuum lies at the root of the bulk of the problems the trans-diverse communities’ experience at the hands of state authorities , there is need to focus on ensuring the extension of Key Populations interventions beyond the LGB sector to include the trans-diverse (and of course intersex) communities so that they constitute a full LGBTI suite, albeit differentiated where specific needs of the communities’ demand it, such as gender affirming surgeries This would then necessitate clearly earmarked central government budget line-items for the trans-diverse communities as part  of Key Populations development.

5. Legal Reforms: Legislation be enacted that outlaw criminalization, demonization and policing of trans diverse communities, discrimination and hate crimes against trans diverse communities.[7] Most importantly, however, the trans-diverse community must be legally enabled to with ease alter their gender on their foundational (birth or ID) documents, and all interlocking document sets downstream in order to ensure their treatment by officialdom as their oriented gender.

6. Healthcare and Education: There is an urgent need to run educational programmes for health-care workers, so that proper scientific understanding becomes widespread; these educational programmes need to be solidly grounded in national equality legislation, and professional ethics codes (especially the Hippocratic Oath). Negotiations need to take place between government, trans advocates, and the health sector regarding all aspects of access to care, medicine and sexual and reproductive health (SRH) services, and gender-aligned accommodation during hospitalization. As part of Key Populations extension, GAHC, trans-sensitive psychological care, and anti-substance abuse and anti-harm initiatives must be tailored for provision to the trans-diverse communities. The extreme stresses under which health-care workers currently operate during the COVID-19 pandemic must not be allowed to push urgent trans healthcare access concerns into the background.

7. Policy & Judicial Reforms: Once the preferred gender status of trans diverse persons is legitimized by policy, it should be bulwarked by an amendment to police standing orders to prevent police from harassing trans-diverse persons in public – or at any time invading their homes purely on the pretext of their gender status. Negotiations need to take place between government, trans advocates, and the policing and judicial sectors regarding all aspects of trans diversity and the law, regarding upholding human rights of the communities, and regarding gender-aligned accommodation arrests and imprisonment.

8. Trans Community & Organizational Alignment: There is a dissonance on approaches to policy reform and other interventions between trans advocacy organizations and the communities they serve, probably driven by poor capacity in the sector. Particular note needs to be taken of daily experiences such as job market discrimination, hate crimes, and the lack of practical support, training, and logistical reform at clinic level. Narrower trans individual concerns that revolve around specific “domestic” issues such as the expressed need to raise families should not be eclipsed by advocacy officers in their focus on broader “societal” issues such as the need for gender-congruent documentation.

9. Public Campaigns: There is a need to broaden the support for the communities especially among progressive NGO, legal, and social circles – to defeat via public campaigns the chauvinistic notion that to be trans-diverse is “unAfrican.” There clearly needs to be an initiation of national dialogues between government, the trans-diverse communities, their legal and other allies, national and religious leadership bodies to bring an end to the prejudiced and persecuting stance of the churches and other faith bodies towards the trans-diverse by educating communities of faith on the natural origins of trans diversity. Accepting church (and other faith) leaders should be co-opted to drive anti-discriminatory campaigns among their peers, their congregations, and the broader public – and their specialised support should be made available to families raising trans children.

10. Funding: Lastly, the trans-diverse communities in African countries require a significant injection of funding for their organizations and for all of their programmes such as the necessary public human rights awareness campaigns and health-access advocacy, for anti-discriminatory law reform campaigns, for self-actualisation support, and for bridging programmes to enable the trans-diverse to complete their education and access decent and secure regular employment.

As Namibian trans activist Deyoncé Naris, national co-ordinator of the Transgender, Intersex and Androgynous Movement of Namibia (TIAMON) says: “We, the activists of Africa, recommend that governments across Africa to take greater care of the trans- and gender-diverse communities in terms of food security and safety. There is a need to increase visibility and awareness on trans- and gender-diverse communities in relation to sexual orientation, gender identity and expression and Sex Characteristics (SOGIESC) Scorecard information and human rights. An increase in advocacy is required with state partners to curb brutality from state actors, and to improve trans communities’ access to their universal rights that are to be upheld our governments. Increased visibility and advocacy within traditional and cultural authorities is also a key requirement.”

***

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognize that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

Data and statistics from the Southern African Trans Forum Situation Analysis (a research and advocacy project with Accountability International) http://bit.ly/TransSituationAnalysis

Covid 19 contributions (in alphabetical order) Mothopeng, Sheriff and Naris, Deyonce with edits from the AI Covid 19 research team (Ciobica, A; Kgositau-Kanza, R; Phele, K; Schmidt, M and Tucker, P)

[1] https://online.fliphtml5.com/cwrmu/niky/

[2] Executive Summary, Southern Africa Trans-Diverse Situational Analysis: Accountability to Reduce Barriers to Accessing Healthcare 4-5.

[3] Global impact of COVID-19  on LGBTI communities, Kaleidoscope Trust  https://kaleidoscopetrust.com/usr/resources/55/final-report-1-global-impact-of-covid-19-on-lgbti-communities.pdf Accessed 1 April 2021.

[4] Streed et al An update on Gender Affirming Health Care https://www.hrc.org/news/an-update-on-gender-affirming-care-during-the-covid-19-pandemic Accessed 1 April 2021.

[5] See https://www.arcusfoundation.org/stories-of-impact/lgbt/supporting-cape-towns-homeless-transgender-women-during-covid-19/Accessed 1 April 2021.

[6] Mokgoroane L, https://opiniojuris.org/2020/12/10/covid-19-and-africa-symposium-centering-the-margins-lgbt-people-and-covid-19/Accessed 1 April 2021.

[7] Note by the Secretary General, Protection against violence and discrimination based on sexual orientation and gender identity https://undocs.org/pdf?symbol=en/A/75/258 Accessed 1 April 2021.

The conditions under which African hospital and clinic staff work during the novel Coronavirus pandemic – often in badly under-resourced and under-staffed circumstances – has a direct bearing on their capacity to effectively provide adequate care to their massively increased patient-loads. Here we will look at the availability of beds and critical care facilities and the relevant key equipment and staff so necessary to those suffering from severe forms of the disease.

Beds & Critical Care Capacity

The extent of critical capacity across the African continent thus received renewed attention at the onset of the pandemic. A US study based on Chinese COVID-19 cases found that 26-32% of all hospitalised patients were admitted into Intensive Care Units (ICU).[1]  ICU is a facility in hospitals that provide life support and specialised care for severely injured and critically ill patients, including provision of equipment such as ventilators that assist in breathing. Yet even in affluent countries, the pandemic overwhelmed critical care capacity.[2]

A systematic review carried out prior to Covid-19 of the Intensive Care Unit capacity of low-income countries, the majority of whom are in Africa, carried out over a decade (2004-2014) revealed that there was a severe lack not only of ICU beds, but also of published data on ICU capacity in more than 50% of countries.[3] The majority of ICUs in low-income countries are situated in large city-based referral hospitals, with an ICU size of an average of 8 beds. The average ratio of ICU beds to hospital beds was 1 to 5, with Nepal and Uganda being the only low-income countries with national ICU bed data available: shockingly, Uganda has only 1 ICU bed per million population; national-level data from other countries was simply unavailable.

A subsequent study² was carried out during the pandemic that used a variety of data sources to estimate Africa’s critical care capacity. This included World Bank estimates of hospital beds per capita, three country audits, one unpublished audit from South Africa, and two published audits from Kenya[4] and Uganda,[5] data from the African Surgical Outcomes Study,[6] and 2017 Global Burden of Disease population estimates. This resulted in estimates of just over a million hospital beds (1,055,846 beds), and 10,784 critical care beds for 1.2 billion people across the continent, equating to 0.8 critical care beds per 100,000 population.[7] A meagre 6 countries had an average of more than 2 critical care beds per 100,000 people, with actual numbers likely lower than estimated. 

While the number of critical beds available are key indicators, other factors affect the critical care capabilities of countries. This includes considerations such as the impact of a limited health-care workforce, particularly inadequate numbers of critical care nurses. Over 50% of ICUs in Africa were unable to obtain a nurse, and other health-care workers such as anaesthesiologists who are typically able to provide ventilator management and critical care support were not available to provide such care because 50% of anaesthesiologists in 78% of African countries are non-physician anaesthetiologists.² There is a lack of data on other key aspects that would allow a holistic and comprehensive assessment of African critical care capacity. Insufficient data exists for factors such as available personal protective equipment, ICU drugs, accessibility of medical oxygen, and resuscitation equipment.²

Another key study by Craig et al spanned 54 African countries[8] compiling national critical care data points which were identified as information concerning the availability of ICU beds, ventilator, physician and non-physician anaesthesia provider numbers, with cross-checking where possible, using data sources such as published government reports, published scientific articles, human rights and humanitarian NGO reports, local and international media in all major continental languages, and in-country informants including government or public health officials, local researchers and health-care workers. Of the 54 African countries, 91% had ICU data available, 85% had ventilator number data available, 87% had data on physician anaesthesiologists and 69% had data on non-physician anaesthesiologists. Limitations included the inability to evaluate whether equipment and health-care workforce capacity was in public or private settings, or whether they were situated in rural or urban environments. Discerning whether equipment and care was available for adult or paediatric populations was also unclear. Nevertheless, the database is believed to be the most comprehensive so far on African critical care capacity. A snapshot into the results follows;

• Hospital beds: Africa ha an average of 135.19 hospital beds and 35.36 physicians per 100,000 people. This ranges from 67.39 beds and 9.57 physicians per 100,000 people in low-income countries on the continent, to 302.50 beds and 115.24 physicians in upper middle-income countries. Southern Africa has the highest average number of hospital beds per 100,000 people while West Africa has the lowest.
• Anaesthesiologists: There is an overall average of 2.42 providers per 100,000 people, both non-physician as well as physician, with a range from 1.24 to 0.66 in low-income countries and Central Africa respectively, to 6.91 and 6.64 providers per 100,000 people in upper middle-income countries and North Africa respectively. North Africa has the highest average number of physician practitioners per 100,000 while West and Central Africa have the lowest.
• ICU beds: From a continent-wide perspective, there are 3.1 ICU beds and 0.97 ventilators per 100,000 people. This ranges from an average of 0.53 ICU beds in low-income countries to 8.59 in upper-middle countries and 33.07 in Seychelles, the only high-income country in the dataset. West Africa has the lowest average number available, with only 1.1 ICU bed per 100,000 people.
• Ventilators: Low-income countries have 0.14 ventilators per 100,000 people while upper-middle income countries have 2.49. East Africa has a paltry 0.23 ventilators per 100,000 people.

It is key to note that the above study is pre-print (not yet peer reviewed). Additionally, though it is comprehensive and an invaluable addition to knowledge in this area, limitations in assessing in-country regional disparities are clearly a key constraint. In 2007, 23% of public and 84% of private hospitals in South Africa had ICU and High Care (HC) units, with only 18% of all beds being HC beds.[9] These were not evenly distributed geographically, with the majority of units and beds, public and private, being available in only three out of nine provinces; Gauteng, KwaZulu-Natal and the Western Cape. The Free State and Eastern Cape had less than 300 beds per province with the remaining 4 provinces having 100 beds or less each. Data on points such as bed availability alone provide an incomplete picture if the concern is assessing access to healthcare, particularly for low-income and rural communities. Not only is it important where the beds are located, but whether they are public or private, and limitations around these factors are crucial obstacles.

Subsequent (pre-print) projections[10] for 52 African countries based on the initial Craig study were made on the number of hospital and ICU beds, as well as ventilators needed at the peak of the pandemic. This was done using four scenarios – if 30, 50, 70, or 100% of patients with severe symptoms seek health services. Analysis was based on an assumption that all people with severe infections would need hospitalization, with 4.72% being in need of ICU care, and 2.3% requiring ventilation. The results are as follows;

• Hospital beds: 62% of African countries were found to have insufficient hospital beds (assuming that all beds are empty and earmarked only for COVID-19 cases) based on the 100% projection. Should only 30% of severe cases seek healthcare then 20% of countries have insufficient hospital beds.
• ICU beds: Even if only 30% of patients sought out care, 71% of countries had insufficient ICU capacity to handle projected needs.
• Ventilators: Although a handful of countries (Cape Verde, Egypt, Gabon, and South Africa) had a sufficient number of ventilators to meet projected needs if 100% of severely infected individuals sought out health services, this is based on all ventilators being functional and available exclusively for COVID-19 patients, while 35 other countries require two or more additional ventilators per 100,000 people.

The lack of a centralised critical care database that takes into account socio-economic factors such as rural and urban availability, and public and private health-care prevents holistic evaluation of health system performance between and within countries, putting barriers in the way of strategic development of health-care policy.³ In the interim, mitigation strategies such as mass training on basic critical care management in resource-constrained environments for non-critical care health workers are essential in minimising unnecessary mortalities across the continent.²

Conclusion & Recommendations

Much of the infrastructural health-care interventions in Africa over past decades have focused on primary clinic development. This was rightly so, as a low-tier, local-site preventative approach helped boost community-level health and disease-combating, especially regarding key challenges like HIV, TB, and malaria, as well as other critical areas such as pre- and post-natal mother and child health-care. This helped mitigate the severity of Africa’s health-care deficit in conditions in which vulnerable communities of all kinds are often exposed to extreme pathologies: prevention truly is better than cure.

COVID-19 pandemic has highlighted the continent’s severe lack of capacity when dealing with more complex health challenges that require highly qualified staff and specialised equipment; as we have demonstrated, this is especially so regarding the dearth of critical-care facilities and the relevant equipment like ventilators and necessary specialists like physician anaesthetists. While there have been some innovations to address this gap – such as the development of cheap, mass-produced ventilators that don’t require electricity, and the upskilling of nurses as non-physician anaesthetists – the shortfalls associated with ICU facilities during the pandemic remain extremely dangerous. In the middle tier, that of hospital-based health-care, it is of great concern that there is also such a marked shortage of normal hospital beds.

This insufficiency, combined with PPE and other shortages, is largely responsible for the stresses experienced by overworked hospital health-care workers during the pandemic. We would encourage the multilateral organizations, financial institutions, and donor bodies engaging with African governments on how best to address the COVID-19 pandemic at all three health-care tiers to take the long view – beyond the pandemic – in building sufficient capacity for clinics, hospitals, and critical-care units in terms of beds, equipment and drugs, and staffing well into the future. This should on the one hand help retain high-qualified medical staff and so somewhat staunch the brain-drain of doctors out of Africa, and on the other hand ensure greater resilience and capacity in African health-care systems.

In the interim, the further, expanded, and escalated delivery of non-electrical ventilators, and the necessary medicines and vaccines, to ICUs and the training of non-physician anaesthetists should help alleviate the impact of the current crisis. It is also apparent that many critical-care facilities are invested only in the capital or primary cities of Africa, so thought should be given to building such capacity in decentralised locations such as provincial capitals and larger rural towns. Input from regional/local community health-focused organizations – especially those that focus on the most vulnerable populations – should be actively sought when making such long-term infrastructural decisions.

***

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

[1]      N Mashishi ‘South Africa has more than 800 ICU beds – but exactly how many is unclear’ (09 April 2020) https://africacheck.org/reports/south-africa-has-more-than-800-icu-beds-but-exactly-how-many-is-unclear/.

[2]      ET Ayebale et al ‘Africa’s critical care capacity before COVID-19’ (2020) 26 Southern African Journal of Anaesthesia and Analgesia at 162-164 https://doi.org/10.36303/SAJAA.2020.26.3.2431.

[3]      S Murthy et al ‘Intensive Care Unit Capacity in Low-Income Countries: A Systematic Review’ (January 2015) 10 Plos Onehttps://doi.org/10.1371/journal.pone.0116949.

[4]      UK Okech et al ‘The operational setup of intensive care units in a low-income country in East Africa.’ (2015) 92 East African Medical Journal at 72-80 in n2.

[5]      P Atumanya et al ‘Assessment of the current capacity of intensive care units in Uganda; A descriptive study.’ (2020) 55 Journal of Critical Care at 95-99 https://doi.org/10.1016/j.jcrc.2019.10.019 in n2.

[6]      BM Biccard et al ‘Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.’ (2018) 391 The Lancet at 1589-98. https://doi.org/10.1016/S0140-6736(18)30001-1 in n2.

[7]      The individual country data and analysis as well as the data set can be found at http://dx.doi.org/10.17632/crsm4s6dc4.1.

[8]      J Craig et al ‘National estimates of critical care capacity in 54 African countries.’ (6 July 2020) MedRxiv preprint doi: https://doi.org/10.1101/2020.05.13.20100727.

[9]      S Bhagwanjee and J Scribante ‘National audit of critical care resources in South Africa – unit and bed distribution’ (2007) 97 S Afr Med J 1311-4.

[10]    J Craig et al ‘Estimating critical care capacity needs and gaps in Africa during the COVID-19 pandemic’ (04 June 2020) MedRxiv preprint doi: https://doi.org/10.1101/2020.06.02.20120147

Part 1: Traditional Practices, Child Marriage & Polygamy

This is the first part of Accountability International’s four-part research report into child abuse during the novel Coronavirus pandemic. The other three parts consist of:

2. Child Poverty, Street Children, and Child Labour;
3. Child Trafficking, Child Soldiering, and Child Sex Tourism and Sexual Abuse;
4. Protections for Pre-Teen Children, Conditions under COVID-19 Lockdown/Curfew, and our Conclusions and Recommendations.

Introduction: The Need to Prioritize Children’s Rights

The experiences of pre-teen children under COVID-19 restrictions including travel bans, lockdowns, and curfews is deeply shaped by their pre-existing social, political, and economic vulnerabilities – differentiated by gender. In particular, entrenched patriarchal, ageist, and sexist attitudes within both traditional African and imported colonial traditions have laid the foundations for and further enabled modern versions of child abuse and exploitation. These includes contemporary forced-labour trafficking, child soldiering, and child-sex tourism amongst others. Policy-makers, donors, and child rights advocates need to pay particular attention to where gender differentiations are counter-intuitive, particularly in countries and circumstances where boy-children are more exploited than girl-children. This is as result of that – data-capture and field research on the conditions under which boys suffer abuse usually falls far short of similar work done on girls. The ageism prevalent in many African societies has created conditions in which adult demands on children are seldom questioned – even when they breach the human rights of the child enshrined in the 1989 UN Convention on the Rights of the Child (CRC).  In such instances perceived wrongdoing by children is often punished by adults with violence, which is never reported as it seen as part of tradition

Government laws often do not prioritize children’s rights in this regard, which makes holding caretakers accountable an almost impossible task. For example, while many countries in Africa have banned corporal punishment, few of the bans cover all settings, allowing for instance for the “disciplinary” beating of children at home though not at school. In  10 out of 29 African countries for which data is known, the percentage of adults who believe that violence is necessary to raise or educate children is over 40%: Cameroon, Eswatini (Swaziland), Ghana, Madagascar, Mauritania, Niger, Nigeria, Sierra Leone, Uganda, and Zimbabwe (see Table below/attached). As a result, it is not surprising that the percentage of children (aged 1-14 years) who experienced any physical punishment and/or psychological aggression by caregivers is exceptionally high across the board, being more than 90% in Benin, Central African Republic, Egypt, Ghana, and Uganda (see Table). While most countries have national laws against statutory rape (the rape of children under the legal age of consent to engage in sex), perceived enforcement levels are not always high. According to the United Nations High Commissioner for Human Rights, children seen as “victims” of abuses are more likely to be treated as passive objects of welfare rather than as rights holders, while children seen as “delinquents” are more likely to be subjected to violence and to end up in the penal system.[i]

Such pre-existing conditions are alleviated only where abusive practices are actively challenged by growing child-rights cultures, especially where these are not only given the force of protective laws, but where such laws are actively implemented. Even stronger rights cultures around children are fostered when there is on-the-ground institutional support, from grassroots community networks and shelters to dedicated child-protection police and courts. We will explore first the traditional and contemporary practices within which children are abused – whether sexually, economically, physically, or psychologically, then examine protective mechanisms against such abuse, and look at how these circumstances have been altered and distorted under COVID-19 conditions, before closing with our conclusions and policy/advocacy recommendations.

Child Marriage & Polygamy

The age of 18 years is generally considered the age of majority, as expressed in the United Nations’ Convention on the Rights of the Child (1989). Thus, religious or civil unions involving any person younger than age 18 are considered to be child marriages according to international conventions, even if domestic legislation allows for younger ages of majority and marriage. Traditions of child marriage, which are widespread in Africa, where an estimated 125-million women and girls alive today, one in three, were married before the age of 18[ii] – create particularly dangerous situations for children. This isespecially so for girls because of the risks of complications associated with unnaturally early pregnancies. As the United Nations Population Fund (UNFPA) puts it, “Child marriage… is a serious violation of girls’ human rights. It denies their right to health care, to education, to live in security and to choose when and whom they marry. Child marriage has dire consequences for girls. It reinforces and compromises the health and security of women and girls. It prevents girls from achieving their full economic and social potential. It subjects girls to sexual violence, risky pregnancies, fistula and HIV. It is linked with early childbearing, leading to death and injury for many young mothers”[iii] as their bodies may not be sufficiently developed for child bearing. It stated that “in Central, Southern and Eastern Africa, at least 30 per cent of young women were married before age 18. In Western Africa, where the percentage is higher (over 40 per cent), child brides are also younger – this sub-region has the world’s highest prevalence of marriage before age 15. The prevalence of child marriage varies across countries, ranging from as low as 2 per cent in Tunisia to as high as 76 per cent in Niger. Of the 10 countries worldwide where child marriage is most common, nine are located in Africa.”

The conditions under which girl children experience marriage are further exacerbated by polygamy where younger wives essentially serve as indentured domestic laborers for the primary wife. Their subservient position often exposes them to neglect of their needs especially education and leisure and to psychological and physical abuse. One study, a rare one on South Africa where polygamous marriage is legal in certain circumstances under African customary law if a court consents to additional wives being added – noted that women in polygamous marriages were significantly less likely to have tertiary education, to have their own money to purchase food and clothes, to have a sexual partner within 5 years of their own age, and were also significantly more likely to have two or more sexual partners.[iv]

In particular, the UNFPA stressed that although some progress had been made, it was far from sufficient in that the average annual rate of reduction in the percentage of women aged 20 to 24 years who were first married or in union before age 18 was a mere 0,6%/year for Africa as a whole. Even for North Africa, where the observed reduction rate was highest at 2,1%/year, it was a tenth of the rate required to eliminate child marriage by 2030. Continentally, “at the current rate, it would take at least 100 years to eliminate the practice.” It noted:

• Child marriage levels have decreased slightly compared to earlier generations; around 2000, nearly 40 per cent of young women were married before age 18.
• Today, levels of child marriage are below 10 per cent in seven countries (Algeria, Djibouti, Eswatini, Namibia, Rwanda, South Africa and Tunisia) compared to just four countries (Algeria, Djibouti, Namibia and Tunisia) 15 years ago.
• Of the seven African countries with child marriage prevalence above 50 per cent, four (Burkina Faso, Central African Republic, Chad and South Sudan) show no signs of decline.

In Africa, Niger tops the rankings of girl child marriage at 76,3% of girls between 20 and 24 who married before the age of 18, followed in Africa by Central African Republic at 67,9%, Chad at 66,9%, Mozambique at 52,9%, Guinea at 51,7%, Burkina Faso at 51,6%, and South Sudan at 51,5%. In fact, only three out of the top 20 countries in the world for child-brides are not African.

Relatively little research exists on child marriage among boys, however, likely because the practice is less common and does not carry the same risk for adverse health outcomes stemming from early pregnancy and childbirth, which are borne by girls. Therefore child marriage studies tend to ignore the marriage of boy-children. As noted by Colleen Murray Gastón and her colleagues in the first global statistical analysis of the available data on the topic,[v] “The practice of child marriage among girls, including its prevalence, the determinants, and the effects on child brides, has been extensively studied... While boys and girls who marry in childhood do not face the same risks and consequences due to biological and social differences, the practice is nonetheless a rights violation for children of both sexes. Similar to child brides, child grooms are forced to take on adult responsibilities which they are not supposed to as the burden it imposes interferes with their childhood development. The union may bring early fatherhood and result in additional economic pressure in the form of providing for the household; it may also constrain the boy’s access to education and opportunities for career advancement.”

They noted that “With the exception of the Central African Republic, which has the highest level [in the world] of child marriage among males (27.9%), the prevalence in every country with data is below 20%, and in many countries is less than 1%. Values range widely across countries in most regions.” For example, in the 23 countries of West and Central Africa for which data is available (99% of the regional male population in those countries), the average percentage of males aged 20–24 years who were first married or in union before the age of 18 stands at 4%, while for the 17 countries of Eastern and Southern Africa for which data is available (77% of the male population there) the figure is 5%. Alongside the Central African Republic, Madagascar at 12,9% also makes the top 20 countries in the world with male child marriages, followed in Africa by Comoros at 11,9%, Mozambique at 9,7%, Chad at 8%, and Malawi and Sierra Leone both at 6,5%. North Africa is not disaggregated from the Middle East in this study, however, but male child marriage is relatively rare in the Arab World.

The study notes: “The countries with the highest levels of child marriage among males differ to some extent from the top-ranking countries for females. Among the 20 countries with the highest levels of child marriage for males and females, only 7 overlap (the Central African Republic, Madagascar, Nepal, Mozambique, Chad, the Dominican Republic and Malawi); among the top 10 countries, there is only 1 in common (the Central African Republic).” Child rights activists constantly monitor the issue: for example, the African Child Policy Forum (ACPF) issued an urgent warning on 3 September 2020 that Somalia “is considering a ‘Sexual Intercourse Related Crimes Bill’. If passed into law in its current form, the bill permits child, early and forced marriage, allows marriage with a child based on subjective consideration of reproductive maturity independent of age, emotional and psychological readiness.”[vi]

Genital mutilation and “muti” murders

Children are additionally vulnerable to harmful traditional practices that are either unprofessionally handled and/or have been outlawed because they conflict with the laws of the land or breach international human rights conventions – and are thus driven underground. In particular, we would like to briefly highlight coming-of-age initiations in which some form of medical procedure, often female genital mutilation (FGM), or male circumcision, is practiced. Female genital mutilation, which involves the cutting away of part of or all the external genitalia of girls, in an attempt to control their sexuality and supposedly protect their chastity, often as a prerequisite for marriage. FGM is already a severe assault on girls’ sexual and reproductive health and rights (SRHR).  According to UNICEF, “Despite being internationally recognized as a human rights violation, FGM has been performed on at least 200 million girls and women in 31 countries across three continents, with more than half of those cut living in Egypt, Ethiopia and Indonesia… FGM can lead to serious health complications and even death. Immediate risks include haemorrhage, shock, infection, urine retention and severe pain. Girls subjected to FGM are also at increased risk of becoming child brides and dropping out of school, threatening their ability to build a better future for themselves and their communities. Indeed, of the 31 FGM-affected countries for which data are available, 22 are among the least developed in the world.”[vii]

Male circumcision, the removal of all or part of the foreskin, as a rite-of-passage for teenage boys, while usually legal and in fact promoted by many medical authorities to mitigate the transmission of HIV, is sometimes performed by inadequately trained practitioners, or in unsanitary conditions – the same uncleaned knife may be used to cut many boys in sequence.  – This often results in infections which, the WHO warned, “can result in acute renal failure, gangrene, tetanus or even death,” citing teenage boy initiations in the Eastern Cape of South Africa where authorities “recorded 243 deaths and 214 genital amputations for circumcisions between 1995 and 2004. To address this, traditional surgeons are now required by law to be officially recognized and registered with the provincial Department of Health.”[viii] However, the law is often not adhered to.

Lastly, we must briefly address the underground practice of “muti” (medicine) murders of children, where their blood or body parts – believed by some to be sources of great spiritual power – are used in outlawed traditional medicines or rituals. This has especially been the case with children living with albinism in many countries. The UNICEF study on trafficking cited above noted that among the factors driving the trade was “high demand for organs and body parts,” both for traditional muti purposes – and for the modern practice of the illegal trade in organs like kidneys and livers for transplant. Because the practice is outlawed, and deliberately shrouded in mystery, it is, however poorly studied.[ix]

Part 2 of this report looks at Child Poverty, Street Children, and Child Labour

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References:

 [i] https://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session19/A-HRC-19-35_en.pdf

[ii] Accelerating Efforts to Eliminate Child Marriage in Africa, African Union & UNICEF, 2018, online at:

[iii] https://esaro.unfpa.org/en/topics/child-marriage

[iv] Socio-demographic and behavioural profile of women in polygamous relationships in South Africa, Musawenkosi L. H. Mabaso, Nthabiseng F. Malope & Leickness C. Simbayi, 2018, online at https://bmcwomenshealth.biomedcentral.com/articles/10.1186/s12905-018-0626-9 . Currently, Muslim customary marriages are not recognized in South Africa as they are potentially polygamous, but the Muslim Marriages Bill is intended to remedy this.

[v] Child Marriage Among Boys: a global overview of available data, Colleen Murray Gastón, Christina Misunas & Claudia Cappa, 2019, online at https://www.tandfonline.com/doi/pdf/10.1080/17450128.2019.1566584?needAccess=true

[vi] https://www.africanchildforum.org/index.php/en/acpf-in-headlines/withdraw-the-sexual-intercourse-related-crimes-bill-and-uphold-the-rights-and-wellbeing-of-children-in-somalia

[vii] https://www.unicef.org/protection/female-genital-mutilation

[viii] https://www.unaids.org/sites/default/files/media_asset/jc1360_male_circumcision_en_3.pdf

[ix] http://forensic-psychologist.co.za/wp-content/uploads/2017/08/Features-and-investigative-implications-of-Muti-Murder-in-South-Africa-2004.pdf

Part 2: Child Poverty, Street Children & Child Labour

This is the second part of Accountability International’s four-part research report into child abuse during the novel Coronavirus pandemic.

Child Labour

According to The Guardian, “Sub-Saharan Africa has the highest number of child labourers in the world – 59 million children between the ages of five and 17 are in the worst forms of hazardous work, with the International Labour Organisation (ILO) estimating that more than one in five children in Africa are employed against their will in quarries, farms and mines.”[i] The ILO says that Africa as a whole “has the largest number of child labourers; 72.1 million African children are estimated to be in child labour and 31.5 million in hazardous work.”[ii] Of these, The ILO defines child labour as: “work that deprives children of their childhood, their potential and their dignity, and that is harmful to physical and mental development. It refers to work that:

• is mentally, physically, socially or morally dangerous and harmful to children; and/or
• interferes with their schooling by: depriving them of the opportunity to attend school; obliging them to leave school prematurely; or requiring them to attempt to combine school attendance with excessively long and heavy work.”

The organization cautions: “Not all work done by children should be classified as child labour that is to be targeted for elimination. Children’s or adolescents’ participation in work that does not affect their health and personal development or interfere with their schooling, is generally regarded as being something positive. This includes activities such as helping their parents around the home, assisting in a family business or earning pocket money outside school hours and during school holidays. These kinds of activities contribute to children’s development and to the welfare of their families; they provide them with skills and experience, and help to prepare them to be productive members of society during their adult life.”[iii]

For the African countries for which UN Children’s Fund (UNICEF) data exists, Ethiopia, Burkina Faso, Chad, and Cameroon had over 40% of their children aged between 5 and 17 years old involved in child labour – including both household chores and economic activities – while for Tunisia, South Africa, Egypt, and Algeria, the figures were under 5%. The ILO says that the worst forms of child labour involve “children being enslaved, separated from their families, exposed to serious hazards and illnesses and/or left to fend for themselves on the streets of large cities – often at a very early age. Whether or not particular forms of ‘work; can be called ‘child labour’ depends on the child’s age, the type and hours of work performed, the conditions under which it is performed and the objectives pursued by individual countries. The answer varies from country to country, as well as among sectors within countries.” In particular the organization is concerned about hazardous work for children involving long hours, night work, dangerous conditions, hazardous substances, and that which may expose them to “physical, psychological or sexual abuse.” The ILO warns especially against:

• “all forms of slavery or practices similar to slavery, such as the sale and trafficking of children, debt bondage and serfdom and forced or compulsory labour, including forced or compulsory recruitment of children for use in armed conflict;
• the use, procuring or offering of a child for prostitution, for the production of pornography or for pornographic performances;
• the use, procuring or offering of a child for illicit activities, in particular for the production and trafficking of drugs as defined in the relevant international treaties;
• work which, by its nature or the circumstances in which it is carried out, is likely to harm the health, safety or morals of children.”

We will examine at several examples of these worst forms of child labour in Part 3, but for because child labour is often driven by poverty, we will first look at street children.

Child Poverty and Street Children

The United Nations defines street children as either “children on the street, who worked on the street and went home to their families at night; children of the street, who lived on the street, were functionally without family support but maintained family links; or abandoned children who lived completely on their own”.[iv] As a result of this range of definitions, it is difficult to quantify how many children can be called street children as well as to adequately address each category as the contexts differ significantly. While all children at risk of abuse and violence, street children are among the most vulnerable of marginalized groups as they are often “invisible” denizens of the urban landscape, so their rights are not adequately considered, especially where communities are complicit in their abuse, especially the adults who make a living off child beggars, pickpockets, drug mules, and prostitutes, or off street children performing may street-related services from washing cars to running errands. Children are not only driven onto the street by poverty, but by abusive family members and this is particularly the case of transgender children. The social disruptions of war and civil strife, and by the loss of parents to HIV/AIDS and other diseases. Because many sleep on the streets, at night they are susceptible to sexual violence, abductions and other abuses too, with police officers often turning a blind eye to these injustices.

In fact, in many countries, police are among the primary perpetrators of abuses against street children. This has been the case in Rwanda and Kenya, for example. Human Rights Watch reported in January 2020 that “Rwandan authorities are rounding up street children in Kigali and detaining them in a so-called ‘transit’ center where guards beat them and there isn’t enough food or water. This is one of the ways Kigali keeps its pristine image – an image often lauded in travel articles.”[v] The Rwandan authorities claim the Gikondo Transit Centre is part of a “rehabilitative process,” but detention conditions are appalling – poor food, no access to lawyers or families, no education or vocational training, and regular beatings for minor infringements. There have been no reports on conditions in the centre since the imposition of a total lockdown in Rwanda on 22 March 2020, Africa’s first country to do so; this demonstrates how the lockdowns and curfews have curbed human rights organizations’ ability to monitor abuses.

In Kenya, The Guardian reported that in May 2016 a brutal police raid on a rubbish dump in Eldoret called California Barracks, which is home to some 700 street children, left 11 children dead and many more injured.[vi] A 2018 study on the causes of death among Eldoret’s approximately 1,900 street children over October 2009 to December 2016 found: “In total there were 100 recorded deaths, 66 among males and 34 among females; 37% of were among those aged ≤18 years. HIV/AIDS (37%) was the most common underlying cause of death, followed by assault (36%) and accidents (10%) for all decedents. Among males, the majority of deaths were attributable to assault (49%) and HIV/AIDS (26%), while females primarily died due to HIV/AIDS (59%)… Most deaths were preventable and require the urgent attention of service providers and policymakers to implement programs and services to prevent premature mortality and uphold children’s rights.”[vii] On 27 March 2020, the Moi Teaching and Referral Hospital in Eldoret was approved as the first COVID-19 testing centre outside Nairobi – but the comorbidities between untreated HIV/AIDS and the novel Coronavirus in Eldoret’s street children have apparently yet to be explored.

Part 3 of this report looks at Child Trafficking, Child Soldiering, and Child Sex Tourism and Sexual Abuse

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References: 

[i] https://www.theguardian.com/sustainable-business/2016/nov/24/child-labour-what-can-we-do-africa-modern-slavery

[ii] https://www.ilo.org/ipec/Regionsandcountries/Africa/WCMS_618949/lang--en/index.htm

[iii] http://www.ilo.org/ipec/facts/lang--en/index.htm

[iv] https://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session19/A-HRC-19-35_en.pdf

[v] https://www.hrw.org/news/2020/01/27/interview-rwandas-street-children-locked-abused

[vi] https://www.theguardian.com/world/2016/oct/10/exposed-kenyan-polices-brutal-attacks-on-street-children

[vii] https://link.springer.com/article/10.1186/s12914-018-0160-8

This is the third part of Accountability International’s four-part research report into child abuse during the novel Coronavirus pandemic.

Child Soldiering

Child Soldiers International (CSI) cautioned that the numbers of children involved in soldiering more than doubled between 2012 and 2018 world-wide, “with a 159% rise and almost 30,000 recruitment cases verified.”[i] Unfortunately, CSI became defunct last year (2019), and its analysis only covers the UN annual reports on children in armed conflict over 2012 to 2017, but these revealed “a total of 29,128 verified cases of child recruitment in 17 countries with an upward trend: the 2018 report, covering the year 2017, details 8,185 verified cases in 15 countries – a 159% rise on the 2013 report, which details 3,159 cases in 12 countries during 2012. The exploitation of girls is rising too. Girls associated with armed groups and forces totaled 893 in the 2018 report; four times more than the 216 recorded in 2017. However, as girls are largely used in ‘support’ roles and kept away from frontlines, they are not often perceived as associated by armed actors or communities. Consequently, they can fall outside official statistics and go unseen by child protection agencies – and thus this number is likely far higher.”

The organization noted that “persistent unrest in Somalia, South Sudan, DR Congo, Central African Republic and elsewhere are all leaving children increasingly exposed to recruitment. Boys and girls are routinely being used as fighters and at checkpoints, as informants, to loot villages and as domestic and sexual slaves. Report data also shows a 40% increase in sexual violence; 951 cases or incidents were verified globally in the 2018 report compared to 679 in 2013. The latest report exposes how girls aged seven were raped in Myanmar, in Somalia they were assaulted when collecting firewood and 13 girls in South Sudan were gang-raped by armed actors.”

Challenges associated with the problem include the difficulty of monitoring the recruitment and militarization of children in conflict zones, and the lack of adequate aftercare for children freed from military service to be reintegrated into civilian society and their families and communities. CSI estimated that of over 55,000 children freed between 2013 and 2018, only 70% received aftercare – though more children escape military bondage than are known about, so the figure is likely lower, but still very problematic. For example, over 2015-2018, 17,141 child soldiers were officially freed in the Democratic Republic of Congo, but only 8,043 (2,294 of them girls) were enrolled in UNICEF support programs. Successful reintegration requires long-term support that is community-centred, and tailored to fit local circumstances.

Child Trafficking

The entrapment of children in sex trafficking and sex tourism is a widespread problem that is difficult to resolve because it is partly enabled by pervasive poverty and social attitudes that endorse it. Kenya provides a striking example of this. The illegal movement and sale of children by crime syndicates is mostly in order for them to be used as forced and unpaid/underpaid labour. Child sex trafficking forms a sub-component of this which is most dangerous to the health and wellbeing of the child. A 2020 study on human trafficking, which is proscribed under the 2000 Palermo Protocol on organized crime noted that: “Although human trafficking is common in different continents of the world, it is endemic in Africa,” where, a 2017 UNICEF study noted 64% of all trafficked children are from Sub-Saharan Africa.[ii] The study stated that despite “several interventions by policy makers and other stakeholders at the continental, regional and national levels… many African countries are still finding it very challenging to combat human trafficking due to ineffective policies and capacity, even where legislation is in place.”

The study noted that the problem was very complex, involving push and pull factors: “The push factors that contribute to human trafficking in Africa include, but are not limited to poverty, political instability, greed, peer pressure, and lack of legitimate and sustainable employment opportunities and corruption. The pull factors include but are not limited to… the demand for cheap and low-skilled labour, the effect of globalisation, weak border control, economic disparities between developed and developing countries.” Thus, for example, rural people often voluntarily leave home for the big cities in an attempt to find jobs that are not available in the countryside – only to find themselves vulnerable to offers of dehumanizing work in the cities.

Each region has its own complex trafficking dynamic. In West Africa, for example, countries “like Nigeria, Ghana, Cameroon and Senegal are source, transit and destination countries for trafficked women and children. Trafficking of young girls from rural areas in countries such as Mali, Benin, Burkina Faso, Togo, and Ghana to work in cocoa plantations in urban Côte d’Ivoire are also documented… Trafficking from and through eastern Nigeria to Gabon have increased in recent years.” Because the root causes of child trafficking are so complicated and “embedded in the countries’ socio-economic, political, and cultural milieus,” the report recommends that the response needs to be the “collective responsibility of all relevant stakeholders, which include, the Government, Non-Governmental Organisations (NGOs), parents, civil societies, religious and educational institutions, and human rights groups, to mention a few.”

Child Sex Tourism & Sexual Abuse

Children involved in sex tourism are not always trafficked however, but are often children who work on the street and go home at night, supporting their families with their earnings. What makes this problem more difficult to root out is its acceptance by many poor families who are reliant on the income derived from “transactional sex” where the child receives – or is promised – food, money, shelter, drugs, or other assistance in exchange for sexual acts. An example is Kenya, where a Global Post story related: “Trace Kenya, a local nonprofit group that works with the United Nations to battle child trafficking, estimates there could be as many as 100,000 child sex workers in Mombasa. The trade extends up and down the coast to the seaside resort towns of Malindi and Diani, according to Trace Kenya. In a 2010 report… UNICEF released numbers on child trafficking in Kenya that revealed that almost a third of girls age 12 and younger in the Mombasa region were involved in prostitution/sex work.  The report stated that European men comprise half of the clients.. Sex tourism has been blamed in Kenya for increasing rates of school dropouts, poverty and illiteracy as school-age children skip class in pursuit of easy money. At the same time, poverty is the main driver behind child sex tourism, say experts. Some parents even urge their children to become involved.” The report also noted: “Teenage boys and 20-something Kenyan men known as ‘beach boys’ also hook up with older white women, usually Western tourists who have flown here specifically for sexual encounters.” While it is simpler to quantify the extent of girls’ exploitation as it often leads to teenage pregnancy and dropping out of school, it much harder to tell how bad the situation is for boy children in this trade.

Trace Kenya claims to have rescued some 10,000 children from the sex tourism trade over 2009-2016 alone, placing them in shelters and providing alternative employment opportunities. A 2018 Reuters report said: “According to the latest data available, one in three girls aged between 12 and 18 in Kenya’s coastal area is engaged in casual sex work, a 2006 report by the U.N. children’s agency UNICEF and the Kenyan government states. That is an estimated 15,000 girls.”[iii] Reuters said that although the figures were out of date, little had changed in the intervening years according to authorities and campaigners: “in cities and towns such as Mombasa, Diani, Kilifi and Malindi dotted along the Indian Ocean coastline, foreign and Kenyan visitors have for years stoked demand for sex with young women – and minors… Deep-rooted sexism ensures deep-seated and daily discrimination, while engrained customs from polygamy to early marriage leave girls and women disproportionately vulnerable.” Hotels and tour operators have attempted to curb child sex by imposing rules on their guests, but the local social acceptance of child prostitution/sex work is also driven by financial benefits to the adults who live off it – the owners of the bars and nightclubs whose under-aged clientele draws sex predators, the taxi drivers who take payments for taking tourists to such spots, and the families of the girls and boys who are able to put extra food on the table.

Former Mozambican First Lady Graça Machel warned in November 2019, citing the African Child Policy Forum (ACPF) report Sexual Exploitation of Children in Africa: A Silent Emergency,[iv] that “Africa is fast becoming the new frontier for online child sexual abuse, especially in those countries with higher internet coverage. Yet very few countries have laws specifically criminalising online sex crimes, and those that do frequently fail to enforce them adequately. Similarly, laws regulating travel and tourism in Africa are weak or non-existent, giving free rein to criminals intent on travelling to the continent with the sole intent of sexually exploiting children. Sex tourists – 90 percent of them men – typically originate from the USA, UK, Italy, Germany, Canada, Korea, and China. They target countries with weak or poorly-enforced laws including South Africa, Nigeria, Ethiopia, Somalia, Uganda, Tanzania, Kenya, Rwanda and Sudan.”[v] However, tourism and technology were not to blame as much as “the corrosive, insidious impact of poverty, inequality and discrimination driven by traditional patriarchal and cultural attitudes.”

The ACPF report  provided that: “A study indicated that in 2015, over a period of one year, more than half of all children in the world aged between two and 17 – about one billion children in total – had experienced some form of violence, including sexual abuse and exploitation. It is estimated that the global prevalence of sexual abuse of children varies between 8% and 31% for girls, and between 3% and 17% for boys. Studies on CSE [child sexual exploitation] in Africa suggest that girls between the ages of 12 and 15 are the most victimised demographic, but that younger girls and boys also experience CSE. Data on child sexual exploitation in Africa is particularly poor, a problem compounded by inadequate and antiquated crime data collection systems.”

The report noted:

• In Kenya, Malawi, Tanzania, Swaziland, and Zimbabwe, lifetime prevalence of sexual violence against children varied between 22% and 37.6%, and between 8.8% and 17% for boys.
• In Malawi, about 22% of females reported having experienced child sexual abuse in one form or another.
• According to a 2016 study in Ghana, child respondents reported having experienced at least one of the following forms of sexual violence: indecent assault (39.4%); defilement (17.9%); rape (8%); and incest (5.4%). Most of these were in the school or home settings.
• In South Africa, a 2016 study revealed that one out of three South Africans, male or female, is at risk of sexual abuse before the age of 17.

As with child trafficking with which it intersects, child sex abuse and sex tourism requires a multi-pronged approach by authorities and activists that focuses on the root causes, in particular poverty and the lack of educational and regular work opportunities. This is true particularly because of its social acceptance and the active complicity of local communities and families.

Part 4 of this report looks at Protections for Pre-teen Children, Conditions under COVID-19, and our Conclusions and Recommendations

[i] https://reliefweb.int/report/world/child-soldier-levels-doubled-2012-and-girls-exploitation-rising

[ii] https://www.intechopen.com/online-first/the-conundrum-of-human-trafficking-in-africa

[iii] https://www.reuters.com/article/us-kenya-tourism-prostitution/child-sex-for-a-dollar-on-kenyas-palm-fringed-beaches-idUSKBN1JA2NE

[iv] https://africanchildforum.org/index.php/en/component/com_sobipro/Itemid,0/pid,1/sid,211/

[v] https://africanarguments.org/2019/11/27/child-sexual-exploitation-is-on-the-rise-governments-are-not-doing-enough-to-stop-it/

Part 4: Protections, COVID-19 Conditions and Recommendations

This is the fourth and final part of Accountability International’s four-part research report into child abuse during the novel Coronavirus pandemic.

Protections for Pre-teen Children

Given the enormity and diversity of the threats experienced by children, it is important not only that protections are grounded in law, but whether those laws are applied, especially regarding specialized child courts and police units, clinical, shelter and other dedicated support services, the actions and abilities of authorities such as police in enforcing the law. As we have seen regarding child sex tourism, changing societal attitudes towards the exploitation of children is a key enabler of rendering protections effective at community level. The World Health Organization-initiated INSPIRE is an evidence-based resource for anyone committed to preventing and responding to violence against children and adolescents. It “presents seven strategies to help countries and communities intensify their focus on prevention programs and services with the greatest potential to reduce violence against children. The seven strategies are: Law Implementation and Enforcement; Norms and Values; Safe Environments; Parent and Caregiver Support; Income and Economic Strengthening; Response and Support Services; and Education and Life Skills.” According to INSPIRE data (see Table), 36 African countries have child protection services – but there is no data for 18 countries, and Libya and Niger have no such services; and the perception of the reach of such services where they exist is low in Central African Republic, Chad, Eswatini, Ethiopia, Seychelles, and Togo. Clinical services especially dedicated to victims of sexual violence are in place in 33 African countries – but there is no INSPIRE data for 18 countries, and no such services in Gabon, Niger, São Tomé and Príncipe, and Senegal; the perception of the reach of such services where they exist are poor in Chad, Mauritania, Namibia, Seychelles, and Togo. Mental health services for victims of sexual abuse are only present in 26 countries for which INSPIRE data is available (there is no data for 19 countries) – and in six countries these only exist at subnational level – while Central African Republic, Guinea-Bissau, Madagascar, Niger, São Tomé and Príncipe, Seychelles, Somalia, Uganda, and Zambia have no such services at all; the perceived reach is poor in Ethiopia, Gabon, Ghana, Mali, Mauritania, Nigeria, and Togo.

In terms of the visibility of child protection in government budgets, the government of Malawi for example recognizes the importance of child protection and its overall benefits and to that effect has several legislation, policies and plans focused on child protection such as the Child Care, Protection and Justice Act (CCPJA) (2010), National Plan of Action for Vulnerable Children (2015-2019), and the National Strategy to End Child Marriage (2018) among others. Despite these commitments, funding allocated for them hardly reflect their significance and this stems from their different objectives and budgets not being sufficiently broken down to indicate to stakeholders how much is being spent on different elements of the system such as response and preventive services, regulation etc. According to the 2018/19 total Government budget, the total visible budget allocation towards child protection translated to approximately MK100 (US$0.14) per child per year. However because the budget lines are not adequately allocated, some resources are probably in indirect budget lines which hinders effective monitoring of these efforts and how much resources they need in order to inform future budget allocation.[i] Despite limited resources, the Government of Malawi has initiated a number of key child protection interventions, including One-Stop Centres, Police Victim Support Units, Children’s Corners, Child Justice Courts, and the Child Protection Management Information System. While not currently not widely available, depending on availability of resources, these services can be taken to national scale. Currently Children’s Corners have been a space for children who have had to take on too much responsibility at a young age and gives them a space to be kids, play and dream about their futures with other children who come from similar situations.[ii]As the INSPIRE data shows, however, the importance of child protection laws and initiatives lies mostly not only in their existence, but in their efficient and accessible application. And it must be stressed that many programs and shelters for children are run not by state agencies but by community and non-profit organizations.

Children’s status under COVID-19 lockdown/curfew

A webinar run on 29 July 2020 by Stellenbosch University's Historical Trauma and Transformation Studies on sexual and gender-based violence (SGBV) in South Africa and Zimbabwe under COVID-19 lockdowns – with panelists Prof Mzi Nduna of South Africa and Dr Naomi Wekwete of Zimbabwe – noted in particular the lack of available data: partly, conditions of lockdown/curfew have prevented field research into the impact of COVID-19. Much data is anecdotal, they said, or where it is based on statistics, derives from individual and often local SGBV organizations with no central reliable national database. There is a lack of data on, for example, whether the police and army street presence actually assisted children abused at home, the impact on femicide, or the impact on unwanted pregnancies resulting from rape and incest. Additionally, the panelists noted the possibility that abuse has in fact not increased, but merely shifted from the public/school domain to the home domain. For one thing, travel restrictions appear to be responsible for an increase in reporting to helplines, as they have reduced physical visits to help centres, they said. They raised the question of “economic abuse,” stating that while household incomes have dropped due to job losses, household expenditure like electricity has actually climbed because of home-stays, so many men are diverting their insecurities as breadwinners into violence on children who are now costing them more. They discussed “social disconnection” under lockdown/curfew, the breaking down of social support networks (family members, peers, school teachers, mentors) for children imposed by social distancing and travel restrictions. In particular we must note that pre-teen children often lack cellphones or airtime or the ability to contact support services or helpful adults outside their immediate environment.

The mandate of Dr Ademola Olajide, the representative of the UN Population Fund (UNFPA) to Kenya, may only intersect with children where it is explicitly focused on ending female genital mutilation – but his comments in an interview with Accountability International[iii] can be taken as a general statement on the conditions faced by vulnerable children under conditions of lockdown or curfew. “For female genital mutilation,” he said, “it has been clear that the initial response to COVID, which was obviously lockdown and the restriction of movement, disrupted response mechanisms.” He said that shelters that had protected girls threatened with FGM and child marriage had been forced to close their doors and so return the girls to their communities where they were under threat of such abuses. Even government responses had been “severely hampered” in that officials could not move around in communities as freely as previously, and where communities could previously call on the assistance of local state functionaries such as county commissioners, they were left to fight the scourge alone.

“We have seen an increased vulnerability to female genital mutilation – and some communities became bolder in exercising this because there are less and less outsiders watching what is going on, so the vulnerabilities of the girls increased.” Deprived of outside assistance, community activists “had to find ways to improve their response mechanisms and end violence against children.” Fortunately, last year, many community leaders made a commitment to end FGM – which was a national priority in Kenya – so communities with such leadership had encouraged community-based organizations to be active against FGM and “tried to galvanize a broader community response.” Still, the breakdown of societal interactions as a result of movement restrictions made it difficult for responsible adults, especially teachers, to monitor the welfare of children who were no longer in their care: “where previously a girl felt it was safe to speak to a teacher – we have lost that.”

Accountability International would like to underline that the general social isolation and vulnerability experienced by many children under the restrictions imposed during the pandemic is made far more acute when children’s sexual orientation and gender identity and expression (SOGIE) is non-conforming and as a result they are subject to additional prejudice. The same concern applies regarding pre-existing prejudices against children living with HIV, with TB, with albinism, who are refugees, and members of marginalized and excluded ethnic and other minority groups. Also, children’s vulnerabilities are likely to be exacerbated by the stigmatization of children living with the novel coronavirus (or suspected of being positive).

Lastly, it must be stressed that there are several childhood comorbidities that may render children vulnerable to COVID-19, despite the low mortality of most children under the pandemic. A report published on 30 July 2020 noted: “A review of 72,314 cases by the Chinese Center for Disease Control and Prevention showed that less than 1% of the cases were in children younger than 10 years and 1% of the cases were in children aged 10 to 19 years… From the currently available data, it seems that children tend to have asymptomatic or mild disease more commonly than adults, but severe cases and even deaths have been reported worldwide in patients younger than 18 years.”[iv] The report noted one study from the USA that demonstrated that the most common comorbidities were chronic lung disease including asthma, cardiovascular disease, and immune suppression. Cautioning that further study was required, it concluded: “Although a distinct pattern of laboratory findings has not emerged as being associated with severity of the disease in pediatric cases of COVID-19, lymphopenia seems to be a risk factor for severe disease in children… Several other aspects could be implicated in the severity of COVID-19 in children, such as coinfection with RSV [respiratory syncytial virus], responsiveness of the immune system, vaccination history, levels of vitamin D, and genetic polymorphisms, but the present paucity of data limits the ability to draw such conclusions.”

Conclusions and recommendations

The shockingly widespread abuse of pre-teen children in Africa is grounded in pre-existing ageist and sexist conditions including child marriage and polygamy, child labour and child soldiering, child sex trafficking, exploitation and sex tourism, child poverty, and the role of traditional customs including female genital mutilation. In various countries and circumstances, children’s experience of abuse is differentiated by gender – and activists must be aware of where the trends differ from what might be expected. Especially, they must be alive to the many varied situations where children have already been exposed to victimization, prejudice, or stigmatization because of their already marginal status – of whatever nature.

The wide variety of vulnerabilities experienced by children across Africa is sobering and, given that the continent leads the world in many key indicators, should be of grave concern to policy-makers who need to urgently foreground the rights of the child as national and transnational priorities. While some abuses such as child sex tourism have abated under COVID-19 conditions because of the inability of international tourists to enter Africa due to flight restrictions, the countries most affected by such crimes have their work cut out for them in not only adopting laws, codes, and mechanisms to prevent the criminal practice, but in dealing with underlying causes such as poverty. Much more difficult to address – yet crucial to the success of any campaign – is community complicity due to ingrained ageist and sexist attitudes, as well as because of the income earned from the child sex trade by families and other actors. If the opportunity is not taken now to build in new protective campaigns and systems, it is sadly likely that practices like child sex tourism and other abuses that require movement such as child trafficking and child labour will only return in great force once travel restrictions are lifted.

It is clear from the uneven protections afforded children officially – and their real lived experience on the ground – that such interventions need not only to be grounded in international conventions and domestic law, but need to be given teeth with specialized child courts, pediatric medical and mental healthcare clinics, and police investigative units, child-friendly spaces, programs, and shelters, and especially, an engaged civil society with community organizations actively monitoring the welfare of their children beyond the school-ground. In particular, the actions of authorities such as police themselves has often proven abusive, especially towards vulnerable refugee or street children; all state agencies need to be adequately and urgently trained in respecting and advancing the rights of children, no matter whether they live in supposedly safe homes or on the streets. We would also like to urgently highlight the need for well-resourced national campaigns to change societal attitudes towards the exploitation and abuse of children through the likes of combating child beatings, marriage, pregnancy, and labour especially. Where social practices such as initiations may expose children to harm, the adults involved must be properly trained and adequate protections for the child integrated into the practices to the satisfaction of community leaders and all involved.

The social isolation experienced by children as a result of being forced by COVID-19 to stay at home – where many abuses originate – needs to be monitored and countered, and government and community social workers must be empowered to have access to homebound children while the pandemic persists, and beyond if necessary. The critical role of community-based activist organizations in carrying most of the burden of protecting children during the current crisis in the absence of much government support needs to be lauded – and supported by international donor agencies.

A key issue in fighting the abuse of young children across the continent, however, is the lack of proper or adequately transnationally comparable data in many areas – particularly regarding sexual abuses inflicted on boy children, but also regarding other under-explored areas such as the increased use of girl soldiers. As Dr Olajide said of the African Union, its role is “to highlight issues and the current status – based on factual evidence – and force decision-makers to put pressure on each other to ensure mechanisms are responsive across the continent, and to cascade the campaign to national level.” He was aware of the critical data shortage in some areas, but also warned of data incompatibility, where statistics could not be compared country to country in the same way as “comparing apples to apples.” If this was not consistently done, response mechanisms would remain as sporadic and patchy as much of the data.

African leaders from community to national, regional, and continental levels must take the disruptions of the pandemic as an ideal watershed opportunity to actively change the outlook for children for the better by building firm protective mechanisms – and rights-grounded social practices.

***

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

---

References: 

[i] https://www.unicef.org/esaro/UNICEF-Malawi-2018-Child-Protection-Budget-Brief.pdf

[ii] https://www.hrw.org/news/2016/11/03/good-news-child-protection-malawi ; https://www.unicef.org/malawi/stories/childrens-corners-offers-hope-youngsters ; https://unicefmalawi.blog/2019/11/11/chaos-at-home-safe-spaces-in-childrens-corners/

[iii] Michael Schmidt to Dr Ademola Olajide via telephone, 2 November 2020.

[iv] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392074/

Tristan Taylor & Delme Cupido (Humanity NPC)

Summary

The true impacts of the novel Coronavirus pandemic will only be felt in the months and years to come, but already the signs point to a trajectory of increased risks of new and perhaps catastrophic infectious diseases emerging in an environment that has been made vulnerable by humanity’s predations upon nature. How humanity chooses to interact with the environment, going forward, may decide whether COVID-19 is a harbinger of other, more severe pandemics to come, or is the moment when we, as a species, recognize that we have to recalibrate and reimagine our relationship with the environment if we are to survive.

In the early weeks and months of the COVID-19 epidemic it was speculated that the spread of the novel Coronavirus might be limited by environmental factors such as tropical heat or polar cold. When it appeared, initially, that COVID-19 was not as deadly in Africa as many had feared, some hopefully suggested that perhaps the warm summer weather in North Africa and the continent’s equatorial regions was slowing the spread of infections. It may be some time before we know for sure but there is, as yet, no evidence to suggest that this was the case.[1] As things stand, there is no conclusive evidence that either weather or climate have a direct impact on the spread of COVID-19.[2] Nor can we speak of COVID-19 having an appreciable effect on the environment. The virus is not something external to the environment, but emerges out of the environment and is very much of the environment. COVID-19 almost exclusively affects humans, and it is our response to the pandemic, rather than the pandemic itself, that will have by far the largest impact on the environment. Climate change remains the largest threat to the continued habitability of the planet, and COVID-19 is best understood as a symptom of human activity. Insofar as climate change has an impact on the environmental determinants of health – clean air, drinkable water, productive soil, biodiversity etc – this will inevitably increase the overall disease burden and stretch the limits of under-resourced states to deal with new health crises, and so indirectly impact on our ability to cope with the pandemic.

There were signs, long before the recorded emergence of COVID-19 in Wuhan, China, however, that human activity was creating the conditions for the emergence of diseases such as the novel Coronavirus. The now infamous “wet markets” in Wuhan may have been where the virus evolved that was able to make the “jump” from animals to humans, but similar markets where live wildlife are caged, sold and slaughtered can be found in numerous countries around the world, including in Africa in countries such as the Democratic Republic of Congo. This is not just a Chinese problem. It is a human problem that is not tied to one country or source, but is of global concern.

Wet markets are the ultimate destination for much trafficked wildlife such as pangolin, bats, monkeys and other species. Whilst robust data during the time of the pandemic is hard to come by, we present several case studies from countries around the continent which suggest that human activity, such as encroachment, trafficking, industrialized agriculture and resource extraction are creating the perfect environment for future plagues. In Kenya, Ethiopia, Uganda and Somalia, plagues of locust have wrought devastation on crops, while the plundering of rosewood in Gambia and Ghana, and the deforestation of the continent as a whole is upsetting ecosystems in unpredictable ways. With attention focused on COVID-19, meanwhile, industry and governments have forged ahead with environmentally damaging activities ranging from nuclear power production to the production of toxic sodium dioxide emissions from coal and gas power plants.

COVID-19 within the environment

Zoonotic diseases

Zoonotic diseases (or zoonoses) are diseases that jump from one species to another. A common – and deadly – viral zoonotic disease well-known in Africa is rabies, transmitted to humans via bite or deep scratch from an infected animal (in 99% of cases a rabid dog). Although rabies is preventable by inoculation of both dogs and humans, it is almost always fatal after the onset of clinical symptoms, and in Africa, the WHO warns that more than 21,400 people die each year of rabies, noting that “the burden of disease is disproportionally borne by rural poor populations, with approximately half of cases attributable to children under 15.”[3] COVID-19 is another such zoonotic disease, jumping from bats as the original host to an intermediate host, probably pangolins, and then onto human beings. Zoonotic diseases are not unusual: 60% of all infectious human diseases have an origin in another species and about 75% of all emerging human infectious diseases are zoonotic: domestic animals (pigs, cattle, chickens, etc) share on average 19 viruses with people while wild animals share an average of 0.23.[4] The novel Coronavirus, otherwise designated as SARS CoV-2, is merely the latest in a series of disease outbreaks, major epidemics or pandemics over the last 100 years that illustrate how human beings are interconnected with other species and how pandemics often have their origin in other species.

Examples of other coronavirus outbreaks include the Severe Acute Respiratory Syndrome (SARS-CoV) of 2003 which had masked civet cats as its intermediary host, Middle East Respiratory Syndrome (MERS-CoV) of 2012 which had dromedary camels as its intermediary host, and the swine flu of 2016 that originated in bats but transmitted to humans via pigs. Other well-known zoonotic diseases include HIV, which is believed to have had primates such a chimpanzees as its natural reservoirs (species of origin), the virus possibly being transmitted to humans who ate or traded in such animals as food as far back as the 1920s. The Zika virus which first broke out in humans in 1947 being transmitted by bites from infected mosquitos, is another example, as is the Ebola virus which most likely originated with African fruit bats and in 1976 (though the actual mode of transmission remains unknown, eating the meat of infected animals might be the culprit). Then there was the “mad cow disease” outbreak in cattle in 1986 which caused a variant of Creutzfeldt-Jakob disease in humans who had eaten infected meat, and the bird flu of 1996 which originated in wild waterfowl but which transmitted to humans via domestic poultry (usually while plucking or slaughtering infected birds).

It is vital to note that prevention of a zoonotic disease pandemic is far cheaper than dealing with a pandemic. The latest estimate is that spending $260 billion over the next ten year on protecting wildlife and forest is required to significantly reduce the risk of another pandemic. This is only 2% of the estimated $11.5 trillion costs of the COVID-19 pandemic to the global economy.[5]

COVID-19 and the environment

To speak of COVID-19 and the environment or the impacts of the virus on the environment is wrong as the virus is a part of the environment, as are human beings. COVID-19 is a natural phenomenon and appears to mostly only affect human beings – and even so, not to the extent of truly deadly pandemics like the bubonic plague, which was also zoonotic. That said, many natural phenomena can have drastically negative impacts on other species and ecologies: human beings ourselves appear to be far more deadly than other forms of life. The Earth has undergone five mass die-off of species over millions of years caused by dramatic climate change – usually as a result of large-scale meteor impacts or volcanic activity. But from our prehistory and drastically escalating from the 16^th through to the 21^st Centuries, we humans have been responsible for the current mass extinction of species. Plant and animal species are often most at risk of extinction when human beings move or migrate to a “virgin” territory. This is mostly due to human activities such as agriculture, mining, construction, and transport. For example, because of the modernization of farming, a quarter of all plant life is today dedicated to meeting human consumption.[6] All these activities have a direct impact on the environment and especially on those species which occur naturally in certain areas.

Scientists specializing in viruses argue that that human impacts on the global environment have created the conditions – for example, human encroachment into forests, wildlife trafficking, and industrialized factory farming – for diseases to jump from non-human species to humans. A recent study in Nature on 5 August 2020 clearly indicates that disturbed natural ecosystems and the transition from wild ecosystems increases the possibility of zoonosis and pandemics. The study clearly indicates that urban and agricultural areas have a higher proportion of zoonotic species than in undisturbed areas, stating:

“The global expansion of agricultural and urban land that is forecast for the coming decades – much of which is expected to occur in low-and middle-income countries with existing vulnerabilities to natural hazards – thus has the potential to create growing hazardous interfaces for zoonotic pathogen exposure.”[7]

There is every indication that this process will only intensify and new instances of zoonotic diseases and pandemics beyond COVID-19 are extremely likely. The emergence of the novel Coronavirus is most likely the product of human impact on the environment: we caused this. For the purposes of this datapoint, and while being aware of the cross-cutting developmental issues such as access to clean water, sewage treatment and related services, we will focus rather on the state of the environment itself and of environmental protections under COVID-19. This is not to deny the notion of environmental justice for human populations – but we want to highlight here the purely environmental aspects of the pandemic.

Data issues

While a zoonotic epidemic has long been predicted by epidemiological, environmental and biological experts, the onset of COVID-19 caught much of the world by surprise. It is an example of how persistent environmental warnings are often ignored: climate change, biodiversity loss, and soil erosion are other examples. As such, and due to the overwhelming attention paid to controlling the pandemic, limited capacity in some states and the obvious impediments due to lockdowns, the robust quantifiable data ideal for indicator progress is simply unavailable at any kind of reasonable confidence level. Therefore, we will look at specific impacts on the environment owing to human responses to the pandemic. These are somewhat mixed between positive and negative. What the specific instances do is suggest is areas of further investigation.

Indicators looking forward

Because the environment is an extremely complex series of interlocking systems, actions taken today can often have impacts that last decades, centuries or even longer – though these long-term effects can be predicted with some certainty. Climate change is a clear example of this: today’s emissions will only cause global warming in a decade or two – but they will do so according to predictable scientific laws. Additionally, borders are human constructs: nature knows no borders or zones of political control; COVID-19 doesn’t require a visa to travel. So in terms of our attempts to deal with environmental problems, causes and impacts, our thinking has to be global. For example, wildlife trafficking isn’t only a Chinese, African, or European problem but rather one which requires cross-border and in fact global cooperation. However, although African countries are unlikely to solve the COVID-19 crisis alone, substantial progress can be made nationally. For example, while South Africa, Libya, Seychelles, Equatorial Guinea, Algeria, and Mauritius – the continent’s highest carbon dioxide (CO₂₎ emitters – can’t solve human-caused climate change by themselves, they do have direct control over its own energy mix and the choice to build coal-fired power plants or not.

And some solutions to environmental crises can indeed be regional. For example, Sierra Leone, Mauritania, and Guinea-Bissau – the African countries whose sea fish-stocks are the nearest to depletion as a result of illegal, unreported and unregulated (IUU) fishing (see Table) – do not have the naval capacity on their own to prevent over-fishing. IUU fishing sees one in four fish off African coasts illegally caught, and costs West Africa alone US$1,95 billion/year in lost fishing value,[8] plus another US$593-million/year in lost household income for mostly subsistence fishing families. Yet regional initiatives are starting to turn the tide: for instance, under West African pressure, China, which operates the biggest fishing fleet off West Africa, has revoked fishing licenses, withdrawn subsidies, and blacklisted ships and captains caught in IUU activities;[9] also, improved regional naval, fisheries, and wildlife inspectorate co-operation has tightened the net around offenders. Healthier African oceans, with sustainable fish-stocks and greater biodiversity, bodes well not only for such marine ecosystems, but the millions of Africans in the coastal communities who live off fishing.

Therefore, meaningful indicators in terms of the environment and zoonotic diseases need to be forward-looking and have an element of global interaction. Also, there are many diseases that jump from wild animals to domestic animals but which do not directly impact human health; however, the impact on human welfare from substantial deaths and culling of domesticated animals (such as sheep, cattle, etc) should be obvious. For example, African swine fever (ASF), emerged in Kenya in 1907 when domestic pigs were introduced to the country. The disease jumped from ticks and wild pigs to domestic pigs and outbreaks have continued ever since across the world. In 2018/19, the outbreak of ASF in China led to the death (either by the disease itself or by culling to prevent its spread) of 40-million domestic pigs. The current ASF outbreak has spread to Poland and beyond.[10] Therefore, in terms of assessing government responses to zoonotic diseases, we should also keep in mind that while new zoonotic diseases may not affect human beings directly, they can have devastating impacts on other species, including those we rely upon for food and other products. We will later suggest actions that are required in order to minimize the risks of another infectious zoonotic disease arising in Africa. We may face a far greater challenge next time unless we prepare now.

Wildlife and Wildlife Products

 Conservation: Kenya, Madagascar, Malawi

Best practice in conservation involves local and indigenous communities, many of whom have, over the course of centuries practiced ways of life, built cultures, and belief systems that are based on conservation rather than overexploitation of their natural environment. This, in turn, drives ecotourism and tourism in general. COVID-19 related restrictions on travel and tourism have brought all this to an abrupt halt. This is certainly the case in Kenya. With tourism at a standstill and many national parks closed, funding for communities has evaporated, in some places by 100%. The knock-on effects are substantially less money for anti-poaching efforts and a rise in poaching, pastoralists moving into parks, and using conservation areas as sources for charcoal production.[11] Charcoal accounts for about 80% of African households' primary energy needs – the continent consumes at least 23-million tons per annum – and is causing widespread deforestation. Increased charcoal production in conservation areas is of considerable concern.[12] Both Madagascar and Malawi, for example, have cut down most of their forests in order to make charcoal. Yet alternative energy sources are extremely rare in Malawi, especially in rural areas.

Rhino poaching: Botswana and South Africa

Rhino horn is the world’s most valuable trafficked animal product, fetching US3,000/pound on the South African black market – and five to ten times that on Asian wholesale black markets, according to a report in National Geographic. The report noted that South Africa is home to almost 70% of the world population of five poaching-threatened species of rhino, with the remainder of Africa’s dwindling population shared between Namibia, Botswana, Zimbabwe, Mozambique, Tanzania, Malawi, Democratic Republic of Congo, and Kenya. Outlawed in 1977, the illicit market in horns is almost exclusively confined to China and Vietnam where in powdered form it is used as a cure-all traditional medicine.[13] In the early months of the pandemic, six rhinos were poached in Botswana.[14] This was interpreted to mean increased rhino poaching as the economic hardship of lockdowns increased. At least in South Africa this has not been the case: the Department of Environment, Forestry and Fisheries reported on 22 May 2020 that rhino poaching was down 50%. The Minster said, “This could be attributed to the reduction in rhino poaching activities to the disruption of the supply chain resulting from the national travel restrictions, including limitations placed on movement across the country.”[15] It remains to be seen if numbers increase post-lockdown, the extent to which is likely to be determined by efforts within the lockdown period to both boost protection, enforcement and prosecution, and to reduce demand. By 2015, Japan, South Korea, Taiwan, and Yemen were no longer significant consumers of rhino horn products – demonstrating that progress can indeed be made in ending the illegal trade.

Pangolin trade: Nigeria, Cameroon, and Gabon

 In the opening months of the pandemic, pangolins were strongly suspected as the intermediate host for the virus since they are infected (asymptomatically) with a coronavirus that has a genetic similarity of between 88.5% and 92.4% with COVID-19.[16]The natural reservoir for the virus is in bats and the notion was that pangolins in Central Africa picked up the virus from bats and then spread an evolved version of the virus via wildlife markets in Wuhan, China. However, recent research (May 2020) from China has indicated this may not be the case. While further research is required, the thesis that pangolins might be involved in the link between animal to human infection remains a distinct possibility. A major Plos Pathogens study on the matter concluded, “In summary, we suggest that pangolins could be natural hosts of Betacoronaviruses with an unknown potential to infect humans. However, our study does not support that SARS-CoV-2 evolved directly from the pangolin-CoV.”[17]

Wildlife trafficking is the fourth largest criminal enterprise in the world, worth up to US$23-billion/year – and pangolins may be the world’s most trafficked animals, their meat eaten by some indigenous communities in South and South-East Asia, their body parts used in traditional medicines in Ghana, Nigeria, South Africa and other Sub-Saharan countries – but especially because their scales are ground to powder and pressed into pills for use as traditional medicine across much of Asia, particularly China, Vietnam, Laos, Thailand, and Myanmar.[18][19] Between 400,000 and 2.7-million pangolins are poached in West and Central African forests (a 150% increase over the last four decades),[20] with Nigeria, Cameroon and Gabon being major focal areas for poaching and trafficking. The primary driver of a massive uptick in pangolin poaching has been the international market, particularly China, and 55% of all pangolin scales seized globally come from Nigeria and 25% of all pangolins are exported through Nigeria.[21] Anecdotal evidence seems to suggest a downturn in pangolin poaching in Nigeria during the COVID-19 pandemic and lockdown as prices for pangolins (and also income from poaching) within Nigeria have dropped dramatically.[22] Seizures of pangolin scales are down by 78% in 2020.[23] However, this could only be temporary, depending upon future demand by, especially, the traditional medicine markets of Asia and Africa.

One extremely positive development in this regard is a recent law promulgated in China, banning the trade and consumption in wildlife. The law states that existing laws that prohibit the “hunting, trading, transportation, and eating of wild animals” must be strictly applied, and increased penalties for violations. It also totally outlawed the consumption of “terrestrial wild animals with important ecological, scientific, and social value,” as well as those animals protected by the state, forbidding the hunting, trading, or transportation of such animals for the purposes of food, whether the animals are reared in captivity or the wild.[24]While the importance of this law cannot be overstated, the effects of which within will only be known over time. Another encouraging sign is public opinion in China: a recent online opinion poll in China, 90% of the 100,000 respondents supported a total ban on the trade in wild animals.[25] A combination of demand reduction and enforcement of the illegal poaching in Central and West Africa may provide a sliver of hope that pangolins might not be hunted to extinction.

Great apes: Uganda

 The United Nations Environment Program (UNEP) has considerable concern regarding the possible vulnerability of great apes in Uganda to the novel Coronavirus, stating:

“Human respiratory pathogens have been transmitted to wild great ape populations many times, sometimes causing extensive ape mortality. Some of these pathogens tended to cause mild disease in adult humans but severe and even lethal outcomes in great apes, such as the human respiratory syncytial virus (HRSV) and human metapneumovirus (HMPV), as well as human coronavirus subtype OC43 infections of wild chimpanzees in 2016. Whether ape morbidity and mortality associated with the new coronavirus, SARS-CoV-2, could be similar to that in humans is unknown.”[26]

It remains to be seen if such a tragedy comes to pass.

 

Climate change

Carbon dioxide and sulphur dioxide emissions: South Africa

Although data-collection is at an early stage, it is clear that restrictions on international and domestic flights, as well as domestic road and rail travel restrictions under confinement regulations have significantly – albeit probably only temporarily – reduced carbon dioxide (CO₂) emissions responsible for global warming. The first peer-reviewed research on the indicator, by the University of East Anglia in May 2020, showed that on 7 April 2020, daily carbon dioxide emissions by the 69 countries that account for 97% of all such emissions dropped by 17% over previous years. This was comparable to putting the clock back on air pollution to the year 2006. This meant that Africa’s highest CO₂ emitter, South Africa (see Table), produced a quarter of a million tons less air pollution each day during the heavy lockdown period of 27 March to 7 April. The university predicted that even with economies restarting as countries emerge from lockdown, the global average for 2020 would even out at about 7.5% below last year’s CO₂ pollution level – a decline that matches what the UN’s Intergovernmental Panel on Climate Change stated in 2018 was necessary to maintain every year to keep global warming below 1.5°C.[27]

Other airborne emissions that are problematic during the pandemic include sulphur dioxide (SO₂) which is produced, for example, by South Africa’s gas-to-petroleum Sasol plants. SO₂ is linked to a variety of severe respiratory ailments and causes low birth weight; cardiac disease and mortality increase on days with higher SO₂ emissions levels[28] – and it is notable that people suffering from asthma, or pneumonia, or cardiovascular disease, for instance, are more likely to die of COVID-19. The impact of unclean technologies on comorbidities with the novel Coronavirus have yet to be adequately measured, but the pandemic provides governments with the opportunity to seriously review their energy-production strategies in favour of cleaner options like solar and wind power.

Drought: South Africa, Namibia, Botswana, and Zimbabwe

Southern Africa has been experiencing a prolonged and severe drought since 2015. The drought has collapsed commercial agriculture in South Africa’s Karoo region, put 500,000 lives at risk in Namibia, and caused ecological degradation in Botswana, and famine in Zimbabwe. This drought is Southern Africa’s first climate change-induced drought. While the impacts of COVID-19 on this situation are unclear, it is worth noting that South Africa halted disaster relief by repealing the declared state of disaster for the drought on 4 July 2020 (originally declared 4 March 2020), apparently in order to focus instead on the declared disaster around the novel Coronavirus.[29] A study in 2018 stated that the likelihood of such human-caused (that is, climate change-originated) droughts recurring in the region had increased more than threefold.[30]

Locust swarms: Kenya, Ethiopia, Uganda, Somalia

Since December 2019, East Africa has been hit by significant swarms of locusts, destroying large swathes of vegetation and crops. Unseasonal rain has meant the swarms have continued throughout 2020. In Kenya alone, the outbreak is the worst for 70 years according to the Financial Times,[31] and is having far-reaching impacts: not just hunger and food insecurity but also violent conflicts between groups over access to remaining grazable lands.[32] Moreover, the travel restrictions and the diversion of resources to response to COVID-19 has hampered efforts to control the swarms. The newspaper reported that the UN’s Food and Agriculture Organization (FAO) was “calling for emergency funding of $70m to combat the locusts through aerial spraying as swarms – some of them billions strong and one the size of Moscow – make their way from Ethiopia and Somalia across Kenya. Uganda and South Sudan – the latter especially vulnerable to hunger after years of civil war – are also at risk… The FAO said that locusts ate their own body-weight in food each day. A swarm the size of Paris could in a single day devour half the amount of food eaten by the entire French population, it said,” warning that the plague risked the food security of the entire sub-region. The Guardian stated that “Kenyan officials have said coronavirus crackdowns have slowed efforts to fight the infestation, as crossing borders has become harder and pesticide deliveries are held up.”[33]

 

COVID-related waste products

Lastly, the response to the novel Coronavirus pandemic has generated waste-management problems of its own. The UNEP has noted: “In response to COVID-19, hospitals, healthcare facilities and individuals are producing more waste than usual, including masks, gloves, gowns and other protective equipment that could be infected with the virus. There is also a large increase in the amount of single use plastics being produced. When not managed soundly, infected medical waste could be subject to uncontrolled dumping, leading to public health risks, and to open burning or uncontrolled incineration, leading to the release of toxins in the environment and to secondary transmission of diseases to humans. Other wastes can reach water sources and add to riverine and marine pollution.”[34] On that last point, the agency went on to note that there were “already alarming amounts of plastics, microplastics, and microfibers pollution in wastewater,” which was finding its way into rivers and seas. The Guardian reported that conservationists were raising the alarm that a surge of disposable pandemic related waste – disposable face-masks, latex gloves, and empty hand-sanitizer bottles – was threatening ocean life.[35]

Yet UNEP also warned that “COVID-19 will lead to a greater production and consumption of household and personal health related products, that could be single-use and contain valuable resources like plastics, textiles, metals, electronics. COVID-19 waste, and any other waste, must be collected and treated adequately to avoid littering or uncontrolled incineration causing impacts to human health, ecosystem quality, biodiversity, including impacts on soil, rivers, coastal lines and in the marine system.” It added that in “the developing world, with limited access to medical support, increased numbers of cases will have to self medicate at home. Proper management of household medical waste will therefore become key to stop further spread of the COVID-19 virus and avoid putting others, including waste workers, at risk.”

Also important to manage was the burning of COVID-related waste, sewerage, sanitation and waste-treatment systems; this is particularly critical because as noted in the journal Science, the disruptions of the pandemic had seen “an abrupt collapse of waste management chains.”[36] A Science Direct study on the problem stated: “The crisis brought upon by the COVID-19 pandemic has altered global waste generation dynamics and therefore has necessitated special attention. The unexpected fluctuations in waste composition and quantity also require a dynamic response from policymakers.”[37] It stated that “biomedical waste, plastic waste, and food waste management – all… have been a major cause of concern during this crisis [and] without active citizen participation and cooperation, commingled virus-laden biomedical waste with the regular solid waste stream pose significant negative health and safety issues to sanitation workers. Single-use plastic usage is set to bounce back due to growing concerns of hygiene, particularly from products used for personal protection and healthcare purposes.”

 

Conclusion

Accountability International focuses on people’s access to their human rights in Africa – and the policies and practices which shape this – but we also recognize that human interactions with the broader natural environment is of critical importance. This is because healthy environments that enable, for example, access to clean drinking water improve the health of human communities themselves, and because sound environmental stewardship can create a sustainable balance between natural resources and human development. We are also concerned that environmental protections, of endangered wildlife for instance, have been pushed to the rear of policy priorities under COVID-19, and that some governments appear to have taken advantage of the distractions of the pandemic to push climate-changing dirty-tech developments.

We prefer to look beyond merely policies for a sustainable “green economy” (on land) and “blue economy” (in water) and instead to advocate for a more holistic approach. This is best based on the intersections between almost half of the United Nations’ Sustainable Development Goals (SDGs) for 2030, where good health and wellbeing (SDG 3), clean water and sanitation (SDG 6), and affordable and clean energy (SDG 7) intersect with sustainable cities and communities (SDG 11) and responsible consumption and production (SDG 12), as well as with climate action (SDG 13) and protections for life in water and life on land (SDGs 14 & 15), So it is rather that we stress that the people living on the continent are themselves an integral – and potentially beneficial – part of its ecosystems, and because the very overlap between human development and formerly wild areas is a seedbed for zoonotic diseases such as COVID-19. As human pressure on the wilds increases, the likelihood of further similar, and perhaps more severe, zoonotic pandemics sweeping the human population is inevitable – but the severity of such epidemics can be softened by implementing progressive ecological policies and practices, starting now.

***

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

[1]      https://directorsblog.nih.gov/2020/06/02/will-warm-weather-slow-spread-of-novel-coronavirus/

[2]     https://www.who.int/news-room/q-a-detail/q-a-on-climate-change-and-covid-19

[3]     Rabies Epidemiology and Burden of Disease, online at https://www.who.int/rabies/epidemiology/en/

[4]      United Nations Environment Program and International Livestock Research Institute. Preventing the Next Pandemic: Zoonotic diseases and how to break the chain of transmission (2020: Nairobi, pg. 11).

[5]     https://www.theguardian.com/world/2020/jul/23/preventing-next-pandemic-fraction-cost-covid-19-economic-fallout

[6]     https://www.pnas.org/content/110/25/10324

[7]     https://www.nature.com/articles/s41586-020-2562-8

[8]    https://www.seafoodsource.com/news/environment-sustainability/african-countries-fighting-back-against-illegal-fishing

[9]    Nicki Holmyard, African Countries Fighting Back Against Illegal Fishing, SeafoodSource, 2018, online at https://www.seafoodsource.com/news/environment-sustainability/african-countries-fighting-back-against-illegal-fishing

[10]  https://en.wikipedia.org/wiki/African_swine_fever_virus

[11]   https://abcnews.go.com/International/experts-kenya-fear-poaching-deforestation-surging-lockdown/story?id=70500218

[12]   https://www.globalcitizen.org/en/content/charcoal-africa-power-good-bad/

[13]   https://www.nationalgeographic.com/magazine/2016/10/dark-world-of-the-rhino-horn-trade/

[14]   https://www.nytimes.com/2020/04/08/science/coronavirus-poaching-rhinos.html

[15]   https://www.environment.gov.za/mediarelease/rhinopoaching_covid19decline

[16]   https://www.nationalgeographic.com/animals/2020/03/pangolins-coronavirus-covid-possibility

[17]   https://journals.plos.org/plospathogens/article?id=10.1371/journal.ppat.1008421

[18]   https://news.mongabay.com/2020/07/nigerias-wildlife-traders-who-weathered-ebola-eye-post-covid-19-boom/https://www.theguardian.com/environment/2020/aug/04/wildlife-forensics-how-a-giant-pangolin-named-ghost-could-help-save-the-species-aoe

[19]   https://www.nationalgeographic.com/magazine/2019/06/pangolins-poached-for-scales-used-in-chinese-medicine/#:~:text=At%20least%2067%20countries%20and,mainly%20been%20heading%20to%20China

[20]  https://conbio.onlinelibrary.wiley.com/doi/epdf/10.1111/conl.12389

[21]   https://www.theguardian.com/environment/2020/jun/09/china-protect-pangolins-removing-scales-medicine-list-aoe

[22]   https://news.mongabay.com/2020/07/nigerias-wildlife-traders-who-weathered-ebola-eye-post-covid-19-boom/

[23]   https://www.theguardian.com/environment/2020/jun/09/china-protect-pangolins-removing-scales-medicine-list-aoe

[24]   http://www.npc.gov.cn/npc/c30834/202002/c56b129850aa42acb584cf01ebb68ea4.shtml

[25]   https://www.theguardian.com/environment/2020/apr/18/covid-19-a-blessing-for-pangolins

[26]    United Nations Environment Programme and International Livestock Research Institute. Preventing the Next Pandemic: Zoonotic diseases and how to break the chain of transmission (2020: Nairobi, pg. 30)

[27]    https://mg.co.za/environment/2020-05-20-covid-19-brings-south-africas-daily-carbon-emissions-down-by-20/

[28]    https://www.iol.co.za/saturday-star/news/government-locks-sa-into-deadly-air-pollution-amid-covid-19-pandemic-45895850

[29]    https://www.timeslive.co.za/news/south-africa/2020-07-18-sa-farmers-rap-repeal-of-state-of-disaster-for-drought/

[30]    https://doi.org/10.1088/1748-9326/aae9f9

[31]     https://www.ft.com/content/40df32fe-4037-11ea-bdb5-169ba7be433d

[32]    https://www.theguardian.com/global-development/2020/may/15/kenyas-pastoralists-face-hunger-and-conflict-as-locust-plague-continues

[33]    https://www.theguardian.com/global-development/2020/apr/13/second-wave-of-locusts-in-east-africa-said-to-be-20-times-worse

[34]    https://www.unenvironment.org/resources/factsheet/covid-19-waste-management-factsheets

[35]    https://www.theguardian.com/environment/2020/jun/08/more-masks-than-jellyfish-coronavirus-waste-ends-up-in-ocean

[36]    https://science.sciencemag.org/content/368/6498/1438.1

[37]    https://www.sciencedirect.com/science/article/pii/S0921344920303694

A critical aspect of the management of the COVID-19 pandemic in many African countries is whether there are districts or regions that are either entirely un-administered by the authorities or are under-administered, for a variety of reasons. Regions that fall entirely outside the ambit of governments’ abilities to respond to the virus largely embrace those that fall under the control of separatist groups or rebels. Regions that are under-serviced fall into three, sometimes interlinked, categories:

1. those which are difficult to reach because of their remoteness or arid/rugged terrain;
2. poor rural areas which under-resourced governments battle to serve, even under normal conditions; and
3. those from which state services including healthcare are deliberately withheld or restricted because their populations are viewed as hostile to the central state.

Africa’s “lawless” third

These conditions are far more widespread in Africa than is usually acknowledged by the authorities, though concentrated in the Sahara, Sahel, and Forest Belt regions. And as such, they are deeply marked by traditional modes of nomadic livelihood that clash directly with state attempts to curb the spread of the novel Coronavirus by closing borders to all but commercial traffic. Nevertheless, there have been a variety of responses to the challenge posed by the pandemic in these regions, some of them remarkably positive, because human rights imposes a duty of healthcare even on authorities widely regarded as illegitimate. The most notable cases we will examine here of viable alternative healthcare administrations are those of two states with contested legitimacy, the Sahrawi Arab Democratic Republic (SADR) which occupies the eastern third of the Moroccan-ruled territory of Western Sahara, and Somaliland, a Horn of Africa republic that seceded from the north of Somalia.

A hint of the breadth of Africa’s un-, under- or alternatively -administered,  regions – which underlines the scope of this crucially unacknowledged issue – was given by a map produced to illustrate a 2015 article in Foreign Affairs and redrawn for the pan-African journal Ogojiii in 2016.[1] The map indicated huge swathes – all of Libya, half of Algeria, much of the Sahara and Sahel, northern Nigeria, the Horn, and a crescent of the African Forest Belt extending from eastern Central African Republic down the eastern border of the DRC – as being beyond central government control. The Foreign Affairs author stated: “By my count, of the 11.7 million total square miles of African continental land mass, roughly four million, or about 34% are out of state control.” By using the term “lawless” third as a catch-all phrase however, it must be stressed that AI does not mean that law is entirely absent in such areas, or that the law is not applicable there – but that it is difficult or impossible in current conditions for recognized governments to assert their authority in such zones.

What is remarkable about the attached map produced by Thomas Heap of HokaHey! for Accountability International based on Warren Roberts and Robyn Swift’s 2015 map for Foreign Affairs is the very close match between the “lawless” third and the regions proving problematic in terms of controlling the novel Coronavirus. This is despite the fact that this zone shifts continually: for example, since 2015, a government has now entrenched itself in Libya around Tripoli thus reducing the “lawless” zone there, while secessionist conflict has broken out in Ambazonia in western Cameroon, extending the “lawless” zone into that country. We believe that if the data was presented at provincial instead of national level, then the areas within the “lawless” third that currently appear to have less of a crisis on their hands – western Mauritania, northern Nigeria, eastern DRC, northern CAR, and northern South Sudan for example – would likely be revealed to in fact have a higher COVID-19 mortality than the rest of their countries and thus more closely conform to the Roberts-Swift map. Regarding the three remaining anomalies, Libya, being embroiled in civil war is likely under-reporting as stated further in this text, while Eritrea is an authoritarian state and is also likely under-reporting; lastly, we will later examine the complex case of Somaliland/Somalia in detail.

     Inhospitable zones

Much of this third of the continent remains un-administered or under-administered because of its inhospitable, remote desert/jungle conditions; in particular this affects border controls and attempts at shutdowns where there are both insufficient authorities available to enforce COVID-19 international movement restrictions and where traditional nomadic (and rebel/smuggler) routes bypass or bribe their way through official checkpoints. In addition, travel time and inadequate methods of travel to healthcare facilities is markedly increased in remote areas. Although it is the state’s responsibility to provide adequate and equitably-accessible healthcare to such areas, it is well-known that many African states lack sufficient funds, medical staff, equipment, and pharmaceuticals to properly meet this duty of care.

     Political rationale

Governments direct few resources – including health infrastructure, healthcare workers, medical equipment, and pharmaceuticals – to such remote and rural provinces because their sparse and nomadic populations. Exceptions would include far-flung mines such as Niger’s uranium mines which produce valuable raw materials and as such are comparatively well serviced and resourced.

Furthermore, a key study on population densities across Africa, in stressing the correlation of isolation to equitable access to healthcare (and other resources) noted that “existing spatially explicit population data across Africa are generally based on outdated, low resolution input demographic data, and provide insufficient detail to quantify rural settlement patterns and, thus, accurately measure population concentration and accessibility.”[2] Accountability International thus continues to highlight the crucial importance of governments having accurate baseline data on which to plan their healthcare – and now COVID-19 – interventions.

     The Sahara, Sahel, and African Forest Belt

The Sahara Desert is an immense expanse of 9,2-million square kilometres that covers all but the Atlas Mountains and Mediterranean coasts of Algeria, Tunisia, Libya, and Egypt, and which also embraces all of Western Sahara and the northern parts of Sudan, Chad, Niger, Mali, and Mauritania, with an average population density of 0,38 people/km² – one of the world’s lowest. Overall, the Saharan countries have fared the worst in Africa in in terms of the documented COVID-19 deaths as a percentage of positive cases (see AI’s Daily Data maps over April-June 2020 for visual evidence of this). The Sahel is the vast semiarid swathe to the south of the Sahara, comprising the rest of Mauritania, most of the rest of Niger, the north of Senegal and Eritrea, and another third each of Mali, Chad, and Sudan, with an average population density of 6 people/km². But these very low average population densities should not be taken as an indication that people do not gather, socialize and interact in significant numbers in certain zones of the Sahara and Sahel and thus do not pose a low risk to novel Coronavirus transmission.

Notably people cluster and move around bodies of water like Lake Chad (2 million people within a 100km radius of the lake’s centre, and 13 million within 300km radius)[3] and along the Nile River (a density of up to 1,165 people/km² along the river’s lower course through Egypt), as well as along the ancient trade routes that traverse the region. Of relevance to COVID-19 is the potential for viral transmission at these points and along these routes. Such population densities in remote, less-developed areas can have very different impacts on access to healthcare: while it improves access in a better-resourced Egyptian Nile valley[4] (Egypt rates 116 out of 189 countries on the UNDP’s 2019 Development Index) – it pushes healthcare beyond reasonable reach in the impoverished Lake Chad region (Chad ranks 187 out of 189). Also, some rural population distributions are counter-intuitive: for example, the Ouargla province of Algeria and the Tombouctou province of Mali – both remote Saharan Desert regions – have high focal population distributions, meaning their rural populations are densely clustered in small settlements, ideal for novel Coronavirus transmission given that these settlements are linked by poorly-monitored/controlled nomadic travel.[5]

Lastly, the African Forest Belt – home to many rebel groups – though mostly sparsely populated, also boasts zones of dense population. Examples include the strife-torn Lake Kivu basin in the eastern Democratic Republic of Congo which has a density of over 400 people/km² - and yet the government only controls half of the North Kivu province bordering the lake’s western shore, the rest being controlled by a patchwork of numerous guerrilla groups.[6] This extreme fragmentation of authority naturally undermines any coherent anti-COVID-19 response (even by the rebels themselves (as we outline below), and even if assisted by international healthcare agencies) in population density conditions which pose a distinct risk of viral transmission in wildly variable and uncontrolled circumstances.

Guerrilla insurgencies: the destruction of healthcare systems

Sparseness of law enforcement, resource allocation, and healthcare access has enabled rebel groups – with a variety of rationales from religious extremism to ethnic separatism – to operate with relative impunity and gives them an opportunity to legitimize themselves by offering the populace alternative services, including healthcare. But this is a rarity: insurgencies usually disrupt and overstress already fragile healthcare infrastructure. An example is north-eastern Nigeria which already had inadequate clinics and too few healthcare workers before the jihadist Boko Haram insurgency began in 2009. The insurgency has to date displaced 2,3 million people (which creates its own severe healthcare challenges including in neighbouring states which absorbed some quarter-million refugees), killed scores of healthcare workers, and destroyed hundreds of clinics, slashing Nigeria’s north-eastern Borno state’s functional healthcare facilities to a third, while a third of its doctors have left the state due to insecurity. Altogether, despite stern countermeasures by the states at the intersection of which it operates – Nigeria, Niger, Chad, and Cameroon – Boko Haram continues to severely disrupt these states’ ability to exercise their duty of care in rebel-controlled areas. In fact, it is feared that Boko Haram and similar groups, in seeking to undermine the legitimacy of their enemy states by spreading unscientific disinformation to counter official COVID-19 containment messages, may create new epicentres for the virus, while their cross-border activities help spread it further.[7]

Similar problems relating to containment of the novel coronavirus can be observed in countries and provinces embroiled in civil war or other severe conflicts such as Nigeria’s Delta, Libya, Central African Republic, Sudan’s Darfur region, South Sudan, and the eastern DRC – although the mortality rates in Libya are North Africa’s lowest, probably because of severe under-testing/reporting in the midst of a bloody civil war that has seen the destruction of healthcare facilities in violation of international humanitarian law. The highest numbers of confirmed cases in Libya have been in the government-controlled enclave of the coastal capital, Tripoli, and in the rebel-controlled desert Sabha province, both under relatively stable administrations which have taken anti-COVID-19 measures – but much of the country is either lawless desert or controlled by the two main competing armies and their allies (currently engaged in large-scale offensives and counter-offensives) as well as jihadist, localist, and tribal militia.

In some cases, such as that in northern Mozambique, rebel groups have taken advantage of the diversion of security forces to lockdown duties to attempt to expand their territories or make fresh claims. Mozambican President Filipe Nyusi stressed that such insurgencies drew resources away from combating the novel Coronavirus:  “The state security services will have to prioritise between the… insurgency, the armed threat posed by the Renamo military junta, post-cyclone reconstruction, and any measures which will be implemented in the country in light of the detection of COVID-19 within Mozambican borders.”[8]

In Cameroon’s Anglophone Ambazonia region, a legacy of underrepresentation in the Francophone central government in Yaoundé spilled over into open secessionist conflict; a year ago, Médicins Sans Frontières (MSF) reported that “violence is also restricting people’s access to healthcare, hindering them from reaching medical centres; interrupting supplies of drugs and equipment; causing medical staff to flee; and forcing health facilities to close.”[9] MSF said all parties to the conflict had been involved in attacks on healthcare workers and facilities. Such disruptions render proper COVID-19 responses extremely difficult or even impossible. The reference to MSF is important in indicating the role of international non-governmental healthcare organisations in attempting, nevertheless, to provide healthcare in rebel-controlled areas – and across the frontlines of ongoing conflicts. Accountability International encourages state and rebel forces on all sides of regional conflicts to allow such medical staff to move unrestricted about their life-saving work in conflict zones as provided by international law.

Western Sahara and the Sahrawi Republic

This general picture of lawlessness or fragmented authority imposes some unique circumstances under which the COVID-19 pandemic is being faced across many parts of Africa – but there are instances of stable yet alternate (and thus often unrecognized) territorial authorities with aspirations to formal government and state status. At either extremity of this supposedly “stateless” third of the continent lie the Sahrawi Arab Democratic Republic (SADR, administered by a government recognised by 40 out of 193 UN member states, 20 of which are AU members) – and Somaliland (administered by a government recognised by only three UN member states, two of them AU members). Regardless of whether the international community recognises these states, in reality they are only “un-administered” in the view of the central governments in Rabat and Mogadishu which lay claim to them; in most other respects, they fall under conventional functioning administrations which provide healthcare to their citizens. Where diplomatic recognition does count, however, is whether these contested territories are able to access adequate COVID-19 testing – and donor or funding partner healthcare support.

Given that the pandemic statistics reported by the Africa Centres for Disease Control and Prevention (Africa CDC) derive from recognised governments only, the figures for what Africa CDC calls “Western Sahara” and “Somalia” have had perforce to neglect conditions in the independently-administered SADR and Somaliland territories. In addition, the World Health Organization (WHO) also has no official coverage of either territory by its Regional Office for Africa (AFRO). This provoked some debate within Accountability International on how we would track the pandemic in areas falling beyond the reach of Rabat and Mogadishu – as well as regions un-/under-administered by other capitals. Matters were further complicated by the lack of independent data from the two contested territories; for example, Africa CDC did not initially distinguish between Morocco and Western Sahara (both its Moroccan and SADR-controlled parts) at all, making it difficult to ascertain the incidence of the virus in both parts of the territory. The first four cases reported in Western Sahara, by the UN mission there (MINURSO) on 4 April 2020, were in the Moroccan-controlled zone – but it was only a month later that Africa CDC distinguished for the first time in its COVID-19 reporting between Morocco and Western Sahara – though its usage of the term appears to exclude the SADR territory.

Within SADR’s zone, on 19 March, the Sahrawi government had announced its implementation of COVID-19 countermeasures including the closure of borders with friendly neighbours Algeria (home to a large Sahrawi expat camp populace near Tindouf who were restricted from visiting the city), and Mauritania. It also created quarantine areas,[10] and the imposition of a “stay-in-your-tent” lockdown policy. On the one hand, this indicates a seriousness by the Sahrawi authorities to exercise their duty of care, but the remoteness and relative poverty of their territory meant that at the time of these measures were implemented, healthcare workers had “just 600 pairs of gloves and 2,000 masks for a population of between 180,000 and 200,000 people.”[11] Unfortunately, the SADR response to the pandemic which has ravaged its Algerian and Mauritanian neighbours has become more of a political football, with observers aligned to Morocco claiming SADR ruling party POLISARIO has blacked out reporting on COVID-19 in the camps and SADR-occupied zones.

Like the Africa CDC, the WHO has had no cases reported to it in either part of the territory.[12] The only reliable reporting appears to be by the MINURSO mission, which “maintains constant liaison with the Moroccan government, POLISARIO and Algerian government to share information and coordinate action.” Its last report, dated 5 June 2020 states: “There have been no new cases in the Tindouf Governorate [of Algeria] since 10 May and still no cases to date in the Saharawi refugee camps or in the Territory East of the Berm,” the embankment that marks the border with Algeria. “The lone death from Covid-19 in Tindouf Governorate remains the only fatal case in MINURSO’s area of operations. All 13 remaining cases in Tindouf Governorate have recovered and been discharged from hospital.”[13] However, the report gives no number of positive cases for the SADR-occupied portion of Western Sahara – and these figures conflict with the supposed zero cases for “Western Sahara” reported by the Africa CDC.

Somalia and Somaliland

On the extreme east of the continent, the widely unrecognized state of Somaliland, which in 1991 broke away from Somalia – itself without a fully functional or authoritative government and state since then – has likewise posed a problem for tracking the progress of the virus, and for attempts to combat it. A report by the Juba-based Rift Valley Institute and its partners warned that this knowledge vacuum, combined with inadequate or inextant health services could turn the Horn of Africa territories into one of the world’s worst epicenters of the pandemic.[14] The internationally recognized government of Somalia in Mogadishu announced the first positive novel Coronavirus case on 16 March and suspended international flights in response, later followed by the suspension of domestic flights. It also tried to prevent the importation of khat (the leaf chewed for its mildly narcotic effects) as a means to limit socializing amongst people who sit together and chew the leaf in close proximity to each other and because actually buying and selling the leaf can lead to virus transmission.

But Mogadishu’s grip on authority is tenuous at best, the government having spent much of its existence in exile in Kenya. By mid-August last year, it could only claim to control the capital and some of the larger cities of the south, with half of the southern towns and most rural areas under the Al Qaeda-affiliated Al Shabab militant Salafist group centered on the town of Jamane – or completely lawless. Most of the central Puntland region (which reported its first COVID-19 case on 19 April) is dominated by the Mogadishu-friendly yet separate unionist armed forces centered on the port city of Bosaso, while Somaliland in the north is under an antagonistic separatist administration based in the city of Hargeisa (with a small hostile Al Shabab and Islamic State presence in the lands between Puntland and Somaliland).[15] The result is that the official Somalia government is unable to enforce any travel restrictions by road – and dogged in its efforts to get COVID-19-related aid to Puntland and even Somaliland (though some of Chinese magnate Jack Ma’s mass donation of testing kits, masks, and protective suits to Africa, having arrived in Mogadishu in late March did reportedly make it to Hargeisa). And the situation is bedeviled by drought, locust storms, flash-flooding, traditional contestation between six major clans, and some 2,6 million people internally displaced due to conflict.

Somaliland reported its first two positive novel Coronavirus cases on 31 March 2020, six days after closing its land borders and ordering incoming airline crews and passengers quarantined for two weeks. On 26 March, it had diverted all developmental funding into combating the pandemic. Khat establishments were closed, mosques issued with social distancing guidelines, social gatherings outlawed, and 574 prisoners pardoned and released, but the crucial lifeline of flights to Ethiopia were maintained. To date, the Africa CDC’s figures have not differentiated between separatist Somaliland and Somalia (including Puntland), with 2,860 positive cases of whom 90 died as of 25 June 2020, though it appears Mogadishu is counting Somaliland in its reporting to the Africa CDC and WHO. Somaliland separately reported at the same date a total of 681 cases of whom 28 had died. On 15 July, Somalia reported 3,083 cases of whom 93 had died, with Somaliland the following day reporting 807 cases of whom 29 had died. Lacking its own testing facilities, the breakaway state has been sending abroad to get test results.

Aid to combat the novel Coronavirus is being sent via Mogadishu – which politically and practically undermines Hargeisa: in late April, the European Union donated €27 million in aid to combat COVID-19 to Somalia, of which €10 million was officially earmarked for Somaliland. Yet it was subsequently reported that in allocating €15 million of the donation to budgetary support in Somalia, €6,5 million for Somalia’s health infrastructure and awareness campaigns, and the remaining €5,5 million to health services at Mogadishu’s Banadir Hospital, Somaliland had been entirely cut out of the donation, despite the EU representative urging civil society to ensure the earmarked portion did indeed reach Somaliland.[16] On 23 June 2020, however, Hargeisa announced the lifting of all anti-COVID-19 measures – though social distancing measures and the quarantining of virus-positive people entering the country remain in force. The government did not give reasons for its reopening of the country but it is likely that its economy cannot longer bear an economic shutdown without external aid – hard to come by as an almost totally unrecognized state.[17] Despite a lack of international support and a precarious health-care system with only half of facilities having essential equipment and only Hargeisa Hospital having any ICU beds at all, Somaliland’s apparent firm commitment to fighting the epidemic – including the raising of $15 million from its tax-base, and a widespread COVID-19 information campaign – should compel the international donor community to put human welfare above politics and send aid directly to Hargeisa.

In a positive development, it was reported on 5 July 2020 that the UK, Denmark, and the Netherlands had approved agreements with Hargeisa under the Somaliland Development Fund to improve critical infrastructure. Notable under COVID-19 was the commitment to improving Somaliland’s “resilience to future pandemics through enhanced water, sanitation and hygiene (WASH) infrastructure”: this involves increasing the water available to Hargeisa by 20% – “enough to meet the needs of an additional 200,000 people,” though deadlines for the water project’s completion were not announced.[18]

Under-servicing and ethnicity

Lastly, we must deal with the fact in many African countries of some regions being deliberately under-serviced by central governments because of their perceived hostility to the incumbent political leadership. This factor is most noticeable in countries where under-serviced regions are the strongholds of ethnicities that are not in power and are thus characterized by the capital as inherently unpatriotic, subversive, or even secessionist. Although in general, normal protest actions have fallen off considerably across Africa under various forms of lockdown or curfew, economic hardship caused by job losses and trading restrictions has seen a resurgence of protest as travel restrictions have eased. Many of these protests – which flout social distancing protections – occur in areas normally seen by governments as “rebellious” such as Algeria’s Kabyle, Zimbabwe’s Matabeleland, or Ethiopia’s Oromia.

Most current reports on healthcare access disparities relating to ethnic minorities focus on conditions in the US, UK, France and other developed countries – ignoring the widespread nature of the problem in Africa. UN High Commissioner for Human Rights Michelle Bachelet warned that under COVID-19, healthcare disparities experienced by ethnic minorities may in part be related to “bias in provision of care [our italics]… People from racial and ethnic minorities are also found in higher numbers in some jobs that carry increased risk, including in the transport, health and cleaning sectors.”[19] Yet in speaking of minorities of African descent – against the backdrop of the #BlackLivesMatter protests – she only mentioned Africans living in minority Diaspora communities outside Africa where COVID-19 death rates are exposing racial inequalities.

Some African ethnicities are privileged with better healthcare access as they have historically held power; some are majorities, yet others are minorities. A study that gave many examples from Sub-Saharan Africa of “large differentials in child mortality among ethnic groups” noted that the “disparities correspond with the prominence of specific ethnic groups in the national political economy. In many countries where heads of state since independence have come from one or two ethnic groups – as in Côte d’Ivoire, Kenya, and Niger – these groups have experienced levels of early child mortality at least one-third lower than those of other groups. In other countries where there have been several transitions in state control, as in Ghana and Uganda, descendants of precolonial kingdoms… have experienced much lower mortality than others. In most countries, the lower mortality of potent ethnic groups – who typically represent small proportions of national populations – is strongly related to economic privilege.”[20]

Such pre-existing ethnicized healthcare access inequalities are only amplified under COVID-19. For example in Burundi, the aftermath of the genocidal civil war between a Tutsi-dominated army and Hutu rebel groups over 1993-2005 that left some 300,000 dead, its healthcare in ruins, and a Hutu political leadership in charge, has seen the authorities enforce 60% Hutu/40% Tutsi ethnic quotas on the staffing of foreign NGOs – including in the healthcare sector. Human Rights Watch noted: “On October 1, 2018, authorities suspended the activities of foreign nongovernmental organizations (NGOs) for three months to force them to re-register, including by submitting new documentation stating the ethnicity of their Burundian employees.”[21]

Some observers have interpreted this move as using affirmative action as cover for reducing civil society space and privileging Hutus within the developmental sector as they have been in government and business.[22] This is also likely to affect Tutsi access to developmental services. The disruption put many healthcare projects months behind schedule, while some NGOs, wary of how the ethnicity data might be misused, exited the country entirely – all of which has undermined Burundi’s COVID-19 response. On 12 May 2020, the Burundian government declared the WHO’s country director and some of its health experts persona non grata as they were critiquing its underreporting of data on the pandemic. A refusal to honestly deal with the data and address the impact of the pandemic amounts, in Accountability International’s view to a deliberate under-administration, under-servicing and thus to a denial of care. On 10 June, President Pierre Nkurunziza, who had refused to take strong measures against COIVID-19 died of a heart attack rumoured to have been brought on by the virus.

Migrants and Internally Displaced Persons

Denial of healthcare in remote borderlands is most often practiced against migrants, refugees, and other non-citizens – as well as internally-displaced persons (IDPs) – even under COVID-19 quarantine. This practice, which is counter to the most basic human rights, is particularly directed at undocumented migrants, for example, undocumented Zimbabwean refugees in South Africa (so-called “medical xenophobia”)[23] – but also in overcrowded, underserviced and under-administered borderland refugee camps in many areas. Often the rationale for this denial of care is that taxpaying citizens supposedly have first right to tax-funded state healthcare – but this is not only a denial of patients’ human rights, but of the universal healthcare (UHC) goals under various international and African health and human rights commitments. An example of this service gap is from Ethiopia where a Reliefweb update on the pandemic in Ethiopia warned that “IDPs living in congested and unsanitary collective centers, spontaneous and planned sites, rental accommodations or shared shelters with relatives in host communities are particularly vulnerable to COVID-19. Migrants and deportees who have recently arrived in Ethiopia currently confined to underserviced Quarantine Centers without basic [non-food items], are similarly at higher risk of transmission.”[24]

Complicating the issue is that most undocumented migrants including asylum-seekers cross international borders not only without going through any proper health checks, but often without even knowing of the existence of the COVID-19 pandemic. For example, the UN’s International Organization for Migration (IOM) reported that just over half of all migrants attempting the exceptionally dangerous crossing into the Gulf States from Somalia via war-torn Yemen were not only unaware of their viral status but had not heard of COVID-19.[25]

In Conclusion

The lack of access to healthcare during the COVID-19 pandemic experienced by millions of Africans as a result of living in ungoverned, under-serviced, rebel-controlled, or poorly-supported alternatively-administered regions raises a unique set of problems for governments, donor agencies, and healthcare professionals combating the novel Coronavirus. Accountability International believes that the sheer scale and persistence of this problem has caused many decision-makers at country and international levels to turn a blind eye to it – with the unfortunate result being the avoidance of the duty of care in this troublesome third of the continent. However, under numerous human rights, humanitarian, and healthcare conventions to which Africa’s governments are signatory – and to which alternate administrations and some though far from all rebel groups claim adherence – the people living in these zones deserve equitable access to universal healthcare including adequate COVID-19 testing, treatment, and care.

An urgent starting point is for all armed groups whether state or rebel to allow international healthcare agencies like MSF and the International Committee of the Red Cross / Red Crescent to do their work in remote and conflict-torn areas unhindered. In addition, the international community needs to immediately put human lives over shallow diplomatic considerations – and provide assistance directly to SADR, Somaliland, and any other contested regions the rulers of which, regardless of their official status, have clearly demonstrated their administrative capacity and their resolve to fighting the pandemic and protecting the people under their care. Lastly, African administrations of all stripes and their international supporters must pay significant attention to the most vulnerable population groups languishing in poor, remote, and under-serviced areas across Africa – especially migrants and displaced persons, and key populations most threatened by the novel Coronavirus. Only by adhering to our UHC commitments – and leveraging the remarkable unity demanded by the universal threat of the pandemic – can we advance equitable healthcare access to all now, thereby establishing a legacy of robust care well after the current crisis is over.

***

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 9 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

***

Somaliland COVID-19 Response Timeline

In Accountability International’s view, though the lifting of most anti-Coronavirus measures in Somaliland on 23 June is worrisome, this timeline demonstrates that the Hargeisa government has responded with alacrity to the pandemic and thus deserves the support of foreign donors and governments in combating the threat – a fact apparently accepted by the World Health Organization (WHO), the United Arab Emirates (UAE), and some European governments which committed aid to the secessionist republic regardless of its diplomatic status.

20 Jan: WHO and Chinese government confirm human-to-human transmission of COVID-19

29 Jan: Somaliland Ministry of Health Development (MoHD) convenes a conference on COVID-19

30 Jan: WHO declares COVID-19 an international public health emergency

5 Feb: MoHD delivers equipment to medical staff at Somaliland’s borders

15 Feb: MoHD addresses House of Elders on Somaliland’s Coronavirus preparedness

23 Feb: MoHD meets Ethiopian Health Ministry on combating COVID-19

16 Mar: Somaliland Cabinet meeting showcases social distancing on TV and in newspapers

19 Mar: MoHD issues sanitary and other rules to protect communities from the pandemic

25 Mar: First two cases of COVID-19 detected in Somaliland; all land borders closed

26 Mar: Somaliland diverts all developmental funds towards fighting COVID-19

7 Apr: Hospitals prepared to test and treat Coronavirus patients

8 April: First foreign-donated medical supplies to fight COVID-19 (from UAE) arrive in Somaliland

13 Apr: MoHD starts novel Coronavirus prevention awareness campaign on YouTube

23 Apr: MoHD runs workshop for health professionals on case management guidelines

28 Apr: A total of 6 cases reported

30 April: MoHD launches COVID-19 information website: https://somalilandcovid19.com/

17 May: A total of 103 cases reported; MoHD counters COVID-19 disinformation

28 May: A total of 257 cases reported; MoHD receives a testing machine from the WHO

1 Jun: European Union delivers medical supplies to seven health facilities; caseload hits 332

10 Jun: A total of 479 cases reported

23 Jun: Somaliland lifts all restrictions except social distancing and quarantine for positive cases

25 Jun: A total of 681 cases reported, including 28 deaths

5 Jul: UK, Denmark and the Netherlands approve aid to Somaliland including WASH improvement

16 Jul: A total of 807 cases reported, including 29 deaths, for 199 recoveries, and 4,374 tests

***

Footnotes:

1 Pierre Englebert, The ‘Real’ Map of Africa: Redrawing Colonial Borders, Foreign Affairs, 8 November 2015, online at: https://www.foreignaffairs.com/articles/2015-11-08/real-map-africa; Michael Schmidt, Charting Africa, Ogojiii, Issue 7, April-May 2016.

2 Catherine Lineard et al, Population Distribution, Settlement Patterns and Accessibility across Africa in 2010, published in 2012, online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3283664/.

3 Lake Chad Resilience and Climate Resilience Action Plan, World Bank, New York City, USA, 2014: http://documents.worldbank.org/curated/en/489801468186879029/pdf/Main-report.pdf

4 Yet it must be cautioned that water, sanitation and hygiene (WASH) in combating COVID-19 is a crucial problem in the Nile Valley as it has one of the world’s lowest rates of fresh water availability per capita in the world (660m³/person/year) as most water taken from the Nile goes to agriculture, and is ranked high by the WHO among lower middle income countries in the number of deaths from water pollution.

5 See Figure 2A in Catherine Lineard et al (2012).

6 See the December 2017 Kivu Security Tracker map online at https://kivusecurity.nyc3.digitaloceanspaces.com/reports/3/Armed%20Actor%20Area%20of%20Control%20Map%20Eng%20Dec%202017.pdf

7 How is Boko Haram Responding to COVID-19? Tony Blair Institute for Global Change, 20 May 2020: https://institute.global/policy/how-boko-haram-responding-covid-19

8 ‘We are dying’: Residents lament rebel attacks in northern Mozambique, Fidelis Mbah, Al Jazeera, 24 March 2020: https://www.aljazeera.com/news/2020/03/dying-residents-lament-attacks-northern-mozambique-200324115552256.html

9 Médicins Sans Frontières project update on Cameroon 23 May 2019: https://www.msf.org/five-things-know-about-violence-cameroon

10 Sahara Press Service, 19 March 2020: https://www.spsrasd.info/news/en/articles/2020/03/19/25151.html

11 Euronews, 10 April 2020: https://www.euronews.com/2020/04/10/stayinyourtent-covid-19-protective-measures-reach-sahara-desert

12 World Health Organization, 1 July 2020: https://covid19.who.int/region/afro/country/eh

13 MINURSO, 5 June 2020: https://minurso.unmissions.org/regular-updates-minurso-covid-19

14 Rift Valley Institute, 1 April 2020: http://riftvalley.net/index.php/news/covid-19-looming-humanitarian-disaster-somali-east-africa

15 Political Geography Now map: https://www.polgeonow.com/2019/08/somalia-control-map-timeline-august-2019.html

16 Somaliland Standard, 21 April 2020: https://somalilandstandard.com/eu-supports-somalias-covid-19-response-with-27-million-euros-somaliland-excluded/

17 Somaliland Standard, 23 June 2020: https://somalilandstandard.com/somaliland-lifts-all-covid-19-related-restrictions/

18 British Embassy Mogadishu, 5 July 2020: https://www.gov.uk/government/news/uk-denmark-and-netherlands-approve-agreements-with-somaliland-government-on-critical-infrastructure-to-improve-peoples-lives

19 The disproportionate impact of COVID-19 on racial and ethnic minorities needs to be urgently addressed – Bachelet, Relief Web, 2 June 2020: https://reliefweb.int/report/world/disproportionate-impact-covid-19-racial-and-ethnic-minorities-needs-be-urgently

20 Martin Brockerhoff and Paul C. Hewett. Ethnicity and child mortality in Sub-Saharan Africa, 1998: https://knowledgecommons.popcouncil.org/departments_sbsr-pgy/246/

21 Human Rights Watch World Report 2020: https://www.hrw.org/sites/default/files/world_report_download/hrw_world_report_2020_0.pdf

22 See for example Stef Vanderginste, Ethnic Quotas and Foreign NGOs in Burundi: Shrinking Civic Space Framed as Affirmative Action, German Institute for Global Area Studies, 2019: https://journals.sagepub.com/doi/full/10.1177/0002039719881460

23 Médicins Sans Frontières https://www.msf.org.za/about-us/publications/reports/no-refuge-access-denied-medical-and-humanitarian-needs-zimbabweans

24 Annexure to Update to the 2020 Ethiopia Humanitarian Response Plan, Reliefweb, May 2020, online at: https://reliefweb.int/sites/reliefweb.int/files/resources/hrp_update_june_2020_ethiopia_.pdf

25 Cara Anna, Associated Press, 25 June 2020: https://apnews.com/9c916d80adda68d43a42ccc04390443e

The World Health Organization (WHO) has warned that “if efforts are not made to mitigate and overcome interruptions in health services and supplies during the COVID-19 pandemic, a six-month disruption of antiretroviral therapy could lead to more than 500 000 extra deaths from AIDS-related illnesses, including from tuberculosis, in sub-Saharan Africa in 2020–2021.” It stressed that “the impact of a [mere] six-month disruption of antiretroviral therapy could effectively set the clock on AIDS-related deaths back to 2008, when more than 950,000 AIDS-related deaths were observed in the region. And people would continue to die from the disruption in large numbers for at least another five years, with an annual average excess in deaths of 40% over the next half a decade.”[1]

The intersections between people living with the human immunodeficiency virus (PLHIV) and/or tuberculosis, the most vulnerable of our marginalized communities, and the threat posed by the current global epidemic is underscored by the dangerous paucity of data on the most affected key populations on anti-retroviral treatment (ART). It is particularly important for health-care and human rights advocates to focus here on women, girls, LGBTIQ people, sex workers, persons who use drugs and other people who are vulnerable for a variety of reasons. People from these communities are marginalized, stigmatized, discriminated against, criminalized, brutalized and even killed because of their sexual orientation, gender expression or identity (SOGIE) as well as their bodily autonomy-related choices such as having an abortion or injecting drugs.

Winnie Byanyima, the executive director of UNAIDS, warned in a global teleconference on COVID-19 and HIV on 7 May that the world faced “two colliding pandemics,” stating: “We are fighting Corona-19 – but must hold the ground for people living with HIV – and also the vulnerable.”[3] A citizen of Uganda, Byanyima red-flagged several key issues relating to the care of PLHIV during the current crisis in Africa in her conversation with renowned South African HIV activist Mark Heywood. Drawing comparisons between the HIV and COVID-19 epidemics, Byanyima said that both had no vaccine or cure and had devastated and taken lives, both had seen the number of new cases soar exponentially, and both required public campaigns to curb disinformation as well as stigmatization and criminalization of those testing positive. The most important similarity, however, was that “the people hurt are the most vulnerable…: pandemics feed on existing inequalities…” She stressed that 40 years of knowledge gained by civil society and community groups in the fight against HIV/AIDS would prove to be a significant resource for those combating the novel Coronavirus outbreak.

Key Populations ART coverage data gap

While UNAIDS statistics for the percentage of each African country’s people living with HIV and receiving ART are available for 53 out of 55 African countries, when it comes to specific data on key populations (KPs – those most at risk of contracting HIV), the lack of data is shocking. For instance, for the indicator showing the antiretroviral therapy coverage as a percentage of the main five key populations living with HIV is available for less than a quarter of African states:[4]

-    ART coverage among sex workers living with HIV: only for 11 out of 55 African countries.
-    ART coverage among men who have sex with men living with HIV: only for 9 countries out of 55.
-    ART coverage among prisoners living with HIV: only for 9 countries out of 55.
-    ART coverage among people who inject drugs: only for 5 out of 55.
-    ART coverage for transgender persons: only 1 out of 55.

This means that on average only 13% percent of possible data is being collected on KP’s ART coverage.

Initial concerns about the potential impact of the COVID-19 pandemic on PLHIV have been somewhat allayed as it seems that people on ART probably face the same risks as anyone else. But the lack of knowledge of ART coverage of these vulnerable groups is of great concern. In addition, Byanyima warned, “if you have infections particularly of the chest” – and here tuberculosis is a very real threat – “and if you have other diseases like diabetes [and] if you have HIV/AIDS, you are not on treatment, your viral load is going down, and you are getting opportunistic infections, you should protect yourself much more, [you] could be more vulnerable than anybody else.”

Diversion of resources

Of greater current concern is the diversion of attention and potential diversion of HIV-earmarked funds and resources away from the virus to fight COVID-19 instead. Byanyima said while that Bill Gates had assured her that the Bill and Melinda Gates Foundation money intended for the fight against HIV would not be moved for the campaign against the novel Coronavirus, UNAIDS was closely watching what funders did with their money under current conditions – and were also monitoring medical manufacturers, to ensure that factories producing condoms did not change to producing masks (and presumably latex gloves) because it was more profitable. The WHO advised PLHIV to stockpile anti-retrovirals for at least one month – but up to six months where possible – in advance because of disruptions to the supply chains, yet it was unclear how this increased demand would be met by suppliers.[5] Byanyima said UNAIDS was as a result closely monitoring supply-chains of both prevention and treatment drugs in Africa – a task made more critical because Africa imports 94% of its pharmaceuticals (worth US$16 billion/annum).[6]

However, Olive Mumba, Executive Director of the Eastern Africa National Networks of AIDS and Health Service Organizations (EANNASO), gave Accountability International an example from Uganda in an interview[7] that whereas pre-pandemic, PLHIV had to restock their own ARVs once every three months, they had to do it every two weeks – in addition, state-imposed travel restrictions made it so difficult for many PLHIV to access ARV treatment. Fear of becoming infected with the novel Coronavirus while going out for their medication put an extra stress on PLHIV seeking treatment. Additional problems she highlighted were that job losses, including among already vulnerable populations like sex-workers and LGBTIQ communities, was putting the nutritional health of many PLHIV at risk as they lacked adequate money to buy food.[8] She gave an example from Botswana where although undocumented migrants (including sex-workers) were legally allowed to access ART as non-citizens, few of them did so as they hid because of police clamp-downs. Additionally, with international borders shut to all but essential cargo traffic, few were able to reach the relative safety of home. Other responses to the current pandemic have had an impact on HIV and TB affected communities: for example, Mumba said, a strike by health-care workers at Malawi’s main referral national hospital over inadequate protective gear and the lack of risk allowances caused services at the hospital to be suspended, which saw patients sent back to regional hospitals which lacked the required specialists.

The most important indicator of a country’s progress in fighting HIV/AIDS is its achievements towards the “90-90-90” agenda launched by UNAIDS in 2014 to end the AIDS epidemic by 2030 by: ensuring that by this year (2020), 90% of people who are HIV infected will be diagnosed, 90% of people who are diagnosed will be on ART, and that 90% of those who receive anti-retrovirals will be virally suppressed. Here the African statistical knowledge is much better – at least as far as the first and second measures are concerned: the percentage of people diagnosed; and the percentage of positive cases on ART.[9] By 2018 Malawi, South Africa, and Zimbabwe had already achieved their goal of 90% of PLHIV knowing their status – which is important as all three countries are considered by many to be epicentres of the disease – while Botswana, Cape Verde, Eswatini (Swaziland), Namibia, and Rwanda had all surpassed that level already. African countries performed better when it came to getting PLHIV onto anti-retrovirals, with 12 topping the 90% target by 2018, but poorly on either achieving or reporting on the percentage of people on ART who achieved viral suppression – the condition in which PLHIV can be considered at equal risk of COVID-19 to anyone else. Only Botswana (91-92-95) and Eswatini (92-93-94) had beat the UNAIDS 2020 targets by 2018.

Co-morbidities between COVID-19 and TB

The intersections between COVID-19 and tuberculosis become obvious, when we understand that both diseases present as potentially fatal respiratory ailments with a nagging cough and high fever as symptoms. This presents a problem because, as Mumba states, “TB patients are stigmatised because they are presumed to have Coronavirus disease.” Also, the pre-existing stigma that TB patients were presumed to be HIV-positive has meant that large numbers have shied away from seeking treatment in the first place. This untracked and untreated “invisible population” of TB patients was highly at risk of contracting the novel Coronavirus because of their respiratory problems.[10] The stigma around HIV, TB, and COVID-19 are compounding and scaring people away from the necessary health-seeking behaviour that is required for them to be tested and treated and for further spread to be prevented. Yet many countries’ quarantine protocols are fatally flawed, Mumba warned, in that all suspected COVID-19 cases are corralled together in communal sleeping and eating spaces, which dramatically raises the risk of people with respiratory and other underlying health conditions contracting the novel Coronavirus.

Nine African countries have achieved a reported 100% of their known HIV-positive TB patients being on antiretrovirals – Comoros, Egypt, Gabon, Libya, Mauritania, Mauritius, São Tomé and Príncipe, Seychelles, and Tunisia – while another 20 countries have achieved in the 90-percentiles. This would bode well for addressing the comorbidities between HIV, TB, and COVID-19 – but the caveat is that this generally solid result (though 14 countries fall under 81%) stands on the shoulders of a much patchier continental achievement record of the percentage of people living with HIV who are on ART in the first place: some countries have a shockingly low showing, including Madagascar (9%), Sudan (15%), and South Sudan (16%) as can be seen in the accompanying scorecards. Additionally, TB mortality is exceptionally high in Lesotho, South Africa, and Namibia – all countries where epidemiologists have warned COVID-19 may entrench itself because of these pre-existing frailties.

Meanwhile, controlled clinical trials are being conducted in various locales around the world to see if various strands of the BCG vaccines used to treat tuberculosis might be of assistance in combating the novel Coronavirus because of their ability to reduce respiratory tract infections by boosting the body’s natural immune system. The initial results appear to be positive according to The Lancet – but are too preliminary at this stage, and the journal echoed the WHO’s warning against the indiscriminate use of BCG vaccines (already in short supply) before any possible efficacy in warding off COVID-19 was clinically proven.[11]

The fightback against HIV, TB, and the novel Coronavirus

One of the largest donors or funding partners on HIV and tuberculosis is The Global Fund to Fight AIDS, TB and Malaria. In mid-May 2020, The Global Fund wrote that programmes against the three diseases would have to continue under COVID-19: “Prevention interventions, case finding, access to medicines, treatment adherence, human rights protections, community engagement and other important aspects of effective disease response must be maintained as we move forward.”[12] An example from Uganda demonstrated how The Global Fund funded local grant activities were combining their COVID-19 funding response with their main programmatic aims: “In support of Uganda's National COVID Preparedness Response Plan, The Global Fund is providing US$4,452,205 to fight COVID-19, shore up critical health systems, and ensure lifesaving HIV, TB and malaria programs continue. As part of the initial response, the Ugandan Ministry of Health has prioritized the purchase of personal protective equipment for health workers and diagnostic tests for COVID-19. Additionally, the Global Fund is coordinating through our main civil society organization partner to strengthen differentiated service delivery models for key populations and people living with HIV in Uganda.”[13]

On 15^th May The Global Fund made funding available through a COVID-19 Response Mechanism (C19RM), with an initial allocation of US$500 million, enabling recipient countries/regions to access an amount of up to 10% of their allocation for countries/regions with an existing allocation for 2020-2022.[14] Funding from the response mechanism is in addition to the funding available through grant flexibilities,[15] [16] as well as support in health product supplies.[17] The Response Mechanism aims to enable recipients “to respond to COVID-19, mitigate the impact on programs to fight HIV, TB and malaria, and initiate urgent improvements in health and community systems.”[18] In addition, under grant flexibilities, the Global Fund has allowed recipients to use up to 5% of their current grant to combat COVID-19 – if there are savings available – and also to reprogram 5% of their current grant: foreseen activities under these guidelines include, but are not limited to, epidemic preparedness assessment, laboratory testing, sample transportation, use of surveillance infrastructure, infection control in health facilities, and information campaigns.”[19] Country and multi-country recipients have been encouraged to use their grant flexibilities first before applying for C19RM funding.[20]

Activists have stressed that it is important for civil society to monitor whether funding to combat COVID-19 – from all donors, across the board – have not in fact been drawn from reserves previously earmarked for HIV and TB. EANNASO’s Olive Mumba said that because most donors’ funding for the current financial cycle had already been allocated, all donors had to be engaged with to ensure HIV and TB funding would not be adversely affected later.

UNAIDS might be monitoring possible resource diversion as Winnie Byanyima promised, but the situation on the ground revealed several instances in which this had already occurred, Mumba warned. Also, she said, “It seems that resources which normally would go into supporting HIV or the TB community, governments are taking that budget to respond to COVID. Our question is ‘are they taking it from the already inadequate health budgets, or taking funding from some other health-related interventions?’” Mumba cautioned that not only funding, but equipment, pharmaceutics, and research were being diverted towards COVID-19: for instance, the US company that manufactured the cartridges used in GeneXpert machines to test for TB and also for HIV viral loads in many African countries appeared to have switched to making cartridges to test for COVID-19 instead.[21]

But she agreed with Byanyima that the current crisis provided health-care workers and advocacy campaigners with a unique opportunity to integrate HIV and TB testing into the novel Coronavirus response. Not to do so – with TB in particular – risks exacerbating the spread and lethality of COVID-19 itself. That window of opportunity is widened, she said, by bringing to bear the decades of experience in fighting HIV and TB: “When it comes to learning from HIV communities – and the TB community is at a high level of learning, and the malaria community just starting to learn – with COVID, it is very true.” She said that the primary lessons which should be applied to the novel Coronavirus were of community mobilization around testing and treatment, of the vital role that grassroots information networks performed in monitoring pandemics, the creation of awareness (including gender and human rights awareness) programmes, the formation of counselling and support groups, and of the importance of social sharing. Also crucially derived from the HIV and TB experience were “community-based monitoring systems,” from survivors who monitor the treatment adherence of patients at home, to mobile apps that monitor stockouts or stigma at health-care centres.

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 31 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

Footnotes:

[1] The Cost of Inaction: COVID-19-related service disruptions could cause hundreds of thousands of extra deaths from HIV, WHO, New York City, USA, 11 May 2020, online at: https://www.who.int/news-room/detail/11-05-2020-the-cost-of-inaction-covid-19-related-service-disruptions-could-cause-hundreds-of-thousands-of-extra-deaths-from-hiv

[2] The Potential Impact of the COVID-19 Response on Tuberculosis in High-Burden Countries: A Modelling Analysis, Stop TB Partnership et al, online at: http://www.stoptb.org/assets/documents/news/Modeling%20Report_1%20May%202020_FINAL.pdf

[3] Online at: https://www.youtube.com/watch?v=AhQQqTmDKbA

[4] UNAIDS, downloaded on 29 April 2020 from UNAIDS database https://aidsinfo.unaids.org/ (see Table).

[5] Q&A: HIV, antiretrovirals and COVID-19, WHO, Geneva, Switzerland, 24 March 2020, online at: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/question-and-answers-hub/q-a-detail/q-a-on-covid-19-hiv-and-antiretrovirals

[6] Economic Impact of the COVID-19 on Africa, UN Economic Commission for Africa, Addis Ababa, Ethiopia, 13 March 2020, online at: https://www.uneca.org/sites/default/files/uploaded-documents/stories/eca_analysis_-_covid-19_macroeconomiceffects.pdf. Africa’s largest importers of pharmaceutics are the European Union (51,5%), India (19,3%), Switzerland (7,7%), China (5,2%), the USA (4,3%), and the UK (3.3%). South Africa is the biggest continental supplier, providing 2,2%.

[7] AI interview with Olive Mumba, 11 May 2020.

[8] https://www.newvision.co.ug/new_vision/news/1518313/covid-19-hiv-positive-people-abandon-arvs-hunger.

[9] UNAIDS data (Treatment cascade) https://aidsinfo.unaids.org/

[10] Hence our Table indicates “estimated incidences” of aspects of TB.

[11] Nigel Curtis et al, Considering BCG vaccine to reduce the impact of COVID-19, The Lancet, 30 April 2020, online at https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)31025-4/fulltext

[12] https://news.trust.org/item/20200511120950-6d9rv and Information on the Response to fight COVID-19, The Global Fund to Fight AIDS, TB and Malaria, Geneva, Switzerland, Regional Platform for Communication and Coordination for Anglophone Africa, News and Updates , 14 May 2020.

[12] Information on the Response to fight COVID-19, The Global Fund to Fight AIDS, TB and Malaria, Geneva, Switzerland, distributed by email, 14 May 2020.

[14] https://www.theglobalfund.org/en/covid-19/response-mechanism/

14 https://www.theglobalfund.org/en/covid-19/response-mechanism/

[16] https://www.theglobalfund.org/en/covid-19/grants/

[17] https://www.theglobalfund.org/en/covid-19/health-product-supply/

[18] https://www.theglobalfund.org/en/covid-19/response-mechanism/

[19] https://www.theglobalfund.org/en/covid-19/grants/

[20] https://www.theglobalfund.org/media/9607/covid19_responsemechanism_faq_en.pdf?u=637251470510000000

[21] The company, Cepheid, is the target of a campaign by, among others, the International Union Against Tuberculosis and Lung Disease, to reduce the price to developing countries of its cartridges for testing for HIV, TB, COVID-19, and other diseases.

Risks of Sexual & Gender-Based Violence under COVID-19

 Movement restrictions imposed in response to COVID-19 have already resulted in a deadly increase in reported sexual and gender-based violence (SGBV), especially intimate partner violence experienced in the home. Such restrictions include rules of full “lockdown” in which all but essential/emergency travel is outlawed, and “curfew” in which travel by the general public is restricted to certain daylight hours. These restrictions have been enforced in varying degrees of severity, but in many African countries have seen much of the population being cooped up in the close confines of their homes for unusually long periods of time. The psychological toll of living at close quarters has combined with other stresses, particularly job losses caused by the pandemic, to produce volatile domestic conditions.

In positive contrast, there is early statistical evidence that the shutting down of much public social life and the increased security force presence on the streets has seen a sharp decrease in sexual crimes such as rape committed in public spaces by perpetrators who are unknown to their victims. Yet in parallel, there is the risk that helplines and shelters for sexual and gender-based violence will become understaffed – either as a result of helpline services being suspended because staff are viewed as non-essential and are not allowed to go in to work or are redeployed to assist in fighting the pandemic, or as shelters are shut down as potential incubators of the virus. In African countries with alarming rates of SGBV, extra consideration must therefore be given to whether undifferentiated lockdown or curfew policies serve the greater good.

Here we will look at a range of gender-related issues under COVID-19, and have separated out a snapshot study of a case in which an alcohol and tobacco sales ban has had mixed results under a total lockdown regime. We will emphasize that a nuanced and inclusive, rather than one-size-fits-all (and thus unintentionally exclusionary) response to the pandemic will help alleviate the danger posed to vulnerable groups, especially women, girls, and LGBTIQ communities, as well as groups that are discriminated against or criminalized.

An increase in SGBV has already been observed in countries as socially diverse as France, Argentina, and Singapore, where reported incidents increased by 25% to 33% since the outbreak of COVID-19.[1] Domestic violence as also increased dramatically in China, where reported cases have tripled during lockdown.[2] Research prior to the Coronavirus disease outbreak had already demonstrated that in Africa, the occurrence of sexual and gender-based violence varied greatly per country, and so different outcomes of COVID-19-related restrictions in each country are to be expected. Prior to COVID-19, in Equatorial Guinea, for instance, 44% of women between the ages of 15 and 49 had experienced intimate partner violence, whereas in The Gambia, only 7% had (see Table 1).[3] The Ebola outbreak in West Africa in late 2013 provides a deeply worrying prior pandemic-response example, for violence against women soared – while at the same time, it was reported that SGBV was deprioritized, unrecognized, or ignored.[4]

Importantly, stigma and discrimination against LGBTIQ people has seen many of the members of this community reporting higher levels of physical, sexual, and emotional violence during the COVID-19 pandemic. Experiences range from being forced to go and stay with family that are homo-, lesbo-, or trans-phobic, to being denied food or a place to stay, or suffering abusive behavior. Job losses under the pandemic, or insecure accommodation arrangements have forced many to move in with partners, or even ex-partners because of the lack of alternative places to stay. Social discrimination, which had already placed such people in a precarious position prior to the COVID-19 crisis, has seen them put under even more severe stress during the pandemic, yet few local authorities have rallied to support them. In Africa, it has been mostly the LGBTIQ community itself and its allied civil society organizations that have provided support, and some funding and relief.

Differences between African countries in their experiences of sexual and gender-based violence could also be a reflection of the capacity of these states to collect relevant data. Evidence-based research still falls short in many African countries, which limits the capacity of governments to make adequately data-driven decisions. The African Population Health Research Centre has advocated for better coordinated systems to collect data on social welfare,[5] an objective pursued by Accountability International and many other NGOs working in the health-access sector. Another challenge is that sexual and gender-based violence is often committed behind closed doors – and it is not even criminalized in many countries, as is frequently the case with marital rape. Therefore, a full picture of the full impact of the COVID-19 pandemic on SGBV in Africa is unlikely to emerge, even well after the storm has passed. Pre-pandemic data, however, shows the canvas on which incidents during the crisis will be painted.

African Heads of State have been largely silent on the looming threats, despite the dire warnings from the UN and civil society for government to put special measures in place that protect women, girls, and LGBTIQ people. For example, an African Union (AU) Bureau of Heads of State and Government communiqué on the African response does not mention SGBV or gender once, nor does it speak to concerns about the effects of restrictive movement measures on these vulnerable and marginalized groups.[6]

Although the risk of gender-related violence in intimate social circles will undoubtedly increase under COVID-19 constrictions, the imposition of effective lockdowns or curfews, taken together with an increased security force presence, can have a different impact on other gender-related crimes, such as rape and sexual assault where the perpetrators and victims are unknown to each other, or do not habitually reside together. Pre-COVID-19 data from showed that in Sub-Saharan Africa, non-partner sexual violence has been documented in 14,8% of all women between the ages of 15 and 49, which is substantially higher than Europe (9,8%), Latin America (10,2%), and Asia (5,3%).[7] Although COVID-19 restrictions may potentially lessen this threat, the UNFPA warned that violence may magnify in vulnerable populations.

In South Africa, non-partner violence appears to have decreased since the outbreak of COVID-19, due to suppressed social and street activity, heightened police visibility, and the reinforcement of the police by 73,000 soldiers in enforcing an initial 35-day full lockdown (none but emergency/essential travel over 27 March to 30 April). A week after their lockdown policy came into effect, the number of reported rapes had declined by 86% (a decrease of 598 cases).[8] However, there were 2,300 reported cases (in a population of 58,7 million people) of sexual and gender-based violence within the first week of lockdown in South Africa,[9] which emphasizes that statistics don’t always reveal the full picture. Therefore, when looking at the risks that COVID-19 policies can pose relating to SGBV, the focus should primarily be on intimate partners and close social and household circles.

The COVID-19 pandemic is exposing many underlying inequalities in socio-economic systems in Africa, of which sexual and gender-based violence is a primary one. Gender discrimination should be considered in every response to this unprecedented public health crisis. The pandemic is still in its early stages, which allows countries the opportunity to address sexual and gender-based violence, empower women, girls, and LGBTIQ persons, and include them in finding solutions. Agencies such as UN Women and UNFPA have already developed guidelines to incorporate gender considerations into national responses to COVID-19.[10] Primarily, governments must ensure that services to prevent and treat SGBV, such as emergency helpline services and domestic violence shelters, remain available not just to women and girls who are considered socially acceptable, but also to other groups who are discriminated against, for example, women who use drugs, trans-diverse people who sell sex, and queer people who are homeless. The LGBTIQ community must be equally included in the provision of services to combat both SGBV and COVID-19, and this must be up front and central and not done in an ad hoc manner.

The public should be sensitized and educated to prevent SGBV that occurs as a result of discrimination and stigma of any kind, fear of infection, restriction of movement, or economic unrest. We further emphasize that national health institutions should make an effort to engage in transparent and honest dialogues with communities whose marginalization is based on sexual orientation and gender identity and expression – and to collect data on the direct and indirect impacts of COVID-19 on sexual and gender-based violence, to better understand and address how policy decisions impact vulnerable members of society differently.

Snapshot: SGBV & restricted substances in South Africa under lockdown

Because South Africa has one of the most comprehensive COVID-19 responses on the continent, it presents an interesting possible case study – presented here in a brief snapshot – of the complex ways in which lockdown policies interact with sexual and gender-based violence. But it must be cautioned that the country also boasts a better capacity to deal with the pandemic than most other African countries, so this should be taken not as an average, but rather as an extreme example. As mentioned in the main piece, a decrease in non-partner was observed, but a substantial increase in intimate-partner and close-family violence is expected. South Africa has also instituted bans on the sale of alcohol and tobacco products, and has reinforced this policy vigorously. Alcohol consumption is known to increase domestic violence and the ban can therefore help to reduce SGBV, but unintended side-effects of the policy need to be taken into consideration. First and foremost, the ban on alcohol and tobacco has provoked much anger, particularly amongst consumers who have become heavily reliant on these products.

As a result, many people started to engage in home brewing, which poses additional health risks such increased accessibility of poor-quality (and even life-threatening) raw and high-proof alcohols. It also brings with it considerable legal, and physical risks, because the ban has encouraged security forces to act with a heavy hand. An additional concern is for the mental health of alcoholics who depend on substance abuse as a coping mechanism. Even in instances where people are so-called functioning alcoholics and have an addiction during specific contexts or times, a sudden and unprepared lack of access to alcohol could increase withdrawal symptoms such as depression and anxiety. And for people who have alcohol use disorder, in some cases a non-controlled withdrawal can even cause death (delirium tremens). Hence, the ban on alcohol during COVID-19 will undeniably prevent many instances of sexual and gender-based violence, but it may easily provoke numerous others.

Lockdowns and curfews have also disrupted illicit drug supplies, with similar concerns for the mental health of drug-dependent persons and the physical safety of those living in close confines with them. The relative inaccessibility of tobacco, alcohol, and illicit drugs has a particular relevance for the trans-diverse community where these substances are significant factors in coping with prejudice and exclusion. For instance, the LGBTQ community consumes 50% more tobacco than the general population,[11] so they are more likely to seek illegal sources of tobacco. Furthermore, most trans-diverse people have experienced discrimination when attempting to access health-care, sometimes being denied of services completely, which could increase their reluctance to seek medical help during the pandemic. Another concern is that trans-diverse people might be forced back into living with their families during lockdown periods, where they will be more vulnerable to people that do not accept them. In places where LGBTQ rights are still absent or homosexual relationships are illegal, which is the case in many African countries, the pandemic will indubitably make their lives even more difficult.

Footnotes:

[1] UN Women publications: https://www.unwomen.org/en/digital-library/publications/2020/04/issue-brief-covid-19-and-ending-violence-against-women-and-girls#view

[2] Wanqing, Domestic violence cases surge during COVID‐19 epidemic, Sixth Tone, 2020: https://www.sixthtone.com/news/1005253/domestic-violence-cases-surge-during-covid-19-epidemic

[3] Global Health Observatory data repository.

[4] Neetu et al, Lessons Never Learned: crisis and gender-based violence, Developing World Bioethics, 2000: https://doi.org/10.1111/dewb.12261

[5] African Population and Health Research Centre’s advocacy : https://aphrc.org/runit/advocacy/

[6] Communiqué of the AU Bureau of Heads of State and Government teleconference meeting, 3 April 2020, online at:

 http://www.thepresidency.gov.za/press-statements/communique-au-bureau-heads-state-and-government-teleconference-meeting%2C-3-april

[7] UNDP Gender Social Norms Index. http://hdr.undp.org/en/GSNI.

[8] Significant reduction in crime since lockdown, South African Government News Agency, 5 April 2020: https://www.sanews.gov.za/south-africa/significant-reduction-crime-lockdown

[9] South African police record 2,300 gender-based violence complaints in first week of lockdown – not 87,000, Africa Check, 9 April 2020: https://africacheck.org/spot-check/south-african-police-record-2300-gender-based-violence-complaints-in-first-week-of-lockdown-not-87000/

[10] What Works to Prevent Violence, Violence Against Women and Girls in Conflict and Humanitarian Crises. (2017). No Safe Place: A Lifetime of Violence for Conflict‐Affected Women and Girls in South Sudan. Retrieved March 30, 2020, from https://globalwomensinstitute.gwu.edu/sites/g/files/zaxdzs1356/f/downloads/No%20Safe%20Place_Summary_Report.pdf

^[11] Buchting et al. (2017) Transgender use of cigarettes, cigars, and e-cigarettes in a national study. American journal of preventive medicine 53(1): e1-e7. https://doi.org/10.1016/j.amepre.2016.11.022

Preventing Mass Famine of the Marginalized: Fiscal Stimulus Packages and Accountability

The impact of COVID-19 is clearly not restricted to medical, health-care, vaccinology, and epidemiological concerns, but has an unprecedentedly broad impact on the global economy and its national and sub-national components. In a dire warning by the International Monetary Fund (IMF), the “Great Lockdown” as it has become known in many quarters, is projected in even a best-case scenario to, in the intermediate term, be the most severe world recession since the Great Depression of 1929-1939.[1] It is therefore imperative that African governments’ dialogues with their constituents, including organized labour, formal and informal sector business, and civil society, on how best to rescue their flagging economies urgently need to be transparent, innovative, and above all inclusive to ensure that starvation due to commercial shuttering and economic shrinkage does not provoke widespread famine.

On April 22, 2020, World Food Program (WFP) chief David Beasley told the UN Security Council that even before the onset of COVID-19 he had warned world leaders that “2020 would be facing the worst humanitarian crisis since World War II” because of factors including “deepening crises in places like South Sudan and… Burkina Faso and the Central Sahel region. The desert locust swarms in Africa… and more frequent natural disasters and changing weather patterns. The economic crisis in… DRC, Sudan, Ethiopia, and the list goes on. We’re already facing a perfect storm.”[2] The WFP chief said that “821 million people go to bed hungry every night all over the world, chronically hungry, and as the new Global Report on Food Crises published today[3] shows, there are a further 135 million people facing crisis levels of hunger or worse. That means 135 million people on earth are marching towards the brink of starvation. But now the World Food Programme analysis shows that, due to the Coronavirus, an additional 130 million people could be pushed to the brink of starvation by the end of 2020.  That’s a total of 265 million people.”

Stating that the “magnitude and speed of collapse in activity that has followed is unlike anything experienced in our lifetimes,” the IMF’s Gita Gopinath in announcing its April edition of quarterly World Economic Outlook,[4] took the position that assuming “that the pandemic and required containment peaks in the second quarter for most countries in the world, and recedes in the second half of this year… we project global growth in 2020 to fall to -3 percent.” That compares very unfavourably to the worst economic shock of recent times, the 2009 financial crisis provoked by the sub-prime housing scam in the USA, in which global growth only fell to -0,1% of real annual gross domestic product (GDP) growth. “Assuming the pandemic fades in the second half of 2020,” Gopinath wrote, “and that policy actions taken around the world are effective in preventing widespread firm bankruptcies, extended job losses, and system-wide financial strains, we project global growth in 2021 to rebound to 5.8 percent. This recovery in 2021 is only partial as the level of economic activity is projected to remain below the level we had projected for 2021, before the virus hit. The cumulative loss to global GDP over 2020 and 2021 from the pandemic crisis could be around 9 trillion dollars, greater than the economies of Japan and Germany, combined.”

But in a worst-case scenario, Gopinath warned: “The pandemic may not recede in the second half of this year, leading to longer durations of containment, worsening financial conditions, and further breakdowns of global supply chains. In such cases, global GDP would fall even further: an additional 3 percent in 2020 if the pandemic is more protracted this year, while, if the pandemic continues into 2021, it may fall next year by an additional 8 percent compared to our baseline scenario.” Such a combined 14% drop would make it scarily close to the Great Depression’s 15% fall – the aftermath of which endured for a decade. While emerging markets and developing economies such as those in Africa are expected to collectively suffer smaller annual GDP growth declines than the more precipitate drop expected in the developed world, the IMF’s data for 2019 and its best-case scenario projections for 2020, and 2021 respectively for Sub-Saharan Africa are: 3,1%; -1.6%; bouncing back to 4.1%. For two key economies on the African continent, those 2020 and 2021 predictions are Nigeria -3.4% recovering to 2.4%, and South Africa -5.8% springing up to 4%.

In an attempt to rescue their economies, most countries have implemented emergency financial stimulus packages of one kind or another. These are baskets of financial regulatory interventions by governments and central banks that help boost flagging economies. Normally, they involve complex interpretations of a fairly simple equation: boosting government spending to improve liquidity (the amount of cash in circulation) thereby stimulating the economy as people have more spending power, so increased demand drives production.

In the COVID-19 response scenario, however, there are two differentiated responses that we have seen in Africa:

1. in non-oil-export-dependent states, government spending is increased, particularly in health-care: either by subsidizing health-care, raising health-care funding, or creating a special COVID-19 fund; and
2. in oil-export-dependent countries, government spending is actually reduced, particularly in imports of non-pharmaceutical, non-food, and non-essential items, while health-care expenditure is either maintained or raised.

Fiscal stimulus packages can also be divided into support for finance, business, and industry and for households and individuals, and thus ranges from boosting liquidity to ensure there is more cash in circulation to compensate for the fall in production and earnings, to subsidizing worst-hit sectors of the economy (particularly manufacturing, retail, hospitality, travel, and tourism, and the freelance and informal sectors), boosting unemployment benefit funds or subsidizing wages for workers standing idle under lockdown, VAT and interest rate cuts to increase spending power, and a range of debt relief measures (housing and vehicle finance, and life, retirement and medical aid repayment suspensions or deferral).

These packages can be enormously expensive, however, so the UN Economic Commission for Africa has warned about the additional debt burden this will place on Africa’s emerging economies if they have to borrow to raise the money. For example, South Africa will implement a ZAR50 billion (US$26,6 billion) fiscal stimulus package, while Nigeria has made US$128,4 million available to rescue its oil-dependent economy – whereas the UN Economic Commission for Africa warns that these countries are already saddled with debt as a percentage of GDP of 55,9% (South Africa) and 55,8% (Nigeria).[5]

So far, it seems the most common financial rescue plans across Africa, select elements of which are noted on the accompanying qualitative table, focus on maintaining payments to workers or subsidizing wages, on freeing up capital to increase market liquidity, and interest rate cuts to improve consumers’ borrowing and buying power. But there is a worrying lack of relief where one would expect it, aimed at the citizenry: “debt holidays,” the temporary suspending or rescheduling of home rental, life, and medical aid payments, and of repayments of loans on homes and vehicles; instead it is feared much emergency support is rather tailored to assist the financial sector and big business, and to further empower the security forces. Clearly these forms of relief, combined with increased spending on, or the creation of social grants (such as old age pensions, disability benefits, assistance for child-headed households, and benefits for unemployed or laid-off workers) should be a key intervention. At the point of the IMF’s measurement (8-16 April 2020) on which our table is based, only 16 out of 54 countries (29%) were providing some form of tax relief.[6] Also, it must be noted that even sound fiscal stimulus packages require adequate implementation – and capacity-building for such implementation if required.

However, of the biggest challenges of fiscal stimulus packages – like that of health-care provision itself – is that of including marginalized populations, especially the poor. According to an International Labour Organization report, in Africa, 85.8% of employment is in the informal sector.[7] In South Africa to cite but one example, the indigenous crafts and curios market alone contributed ZAR11 billion (US$585,6 million) to GDP and employed about 38,000 people – compared to to ZAR2,63 billion (US$139,8 million) and 44,000 jobs in fishing.[8] Living subsidies and feeding and other emergency assistance schemes for the informal sector – denied the ability under containment measures to trade in public markets and often unable to access its traditional supply and sales routes – are critical to the wellbeing of traders and the extended networks of people who survive on their earnings.

Poverty is a cross-cutting driver of vulnerability and marginalization in all societies, especially unequally disadvantaging women and girls who already have lower earning power, and people such as migrants, the mentally ill, people living with disabilities, and lesbian, gay, bisexual, transgender, intersex and queer persons (LGBTIQ) who were even in pre-COVID-19 circumstances pushed to the margins of economic activity. As the WFP’s Beasley stated: “The economic and health impacts of COVID-19 are most worrisome for communities in countries across Africa as well as the Middle East, because the virus threatens further damage to the lives and livelihoods of people already put at risk by conflict.”

Warning that death rates from starvation alone could soar to 300,000/day over the next three months if WFP emergency assistance proved unequal to the task, he stressed: “if we don’t prepare and act now – to secure access, avoid funding shortfalls and disruptions to trade – we could be facing multiple famines of biblical proportions within a short few months.” So while fiscal stimulus packages are supposed to even-handedly help both households and high finance, governments need to transparently engage in dialogue about how to uplift their largest vulnerable population group, the poor.

Footnotes:

[1] Gita Gopinath, The Great Lockdown: Worst Economic Downturn Since the Great Depression, International Monetary Fund Blog: https://blogs.imf.org/2020/04/14/the-great-lockdown-worst-economic-downturn-since-the-great-depression/

[2] WFP chief warns of huger pandemic as CVID-19 spreads, World Food Program, 22 April 2020: https://www.wfp.org/news/wfp-chief-warns-hunger-pandemic-covid-19-spreads-statement-un-security-council

[3] 2020 - Global Report on Food Crises, World Food Program: https://www.wfp.org/publications/2020-global-report-food-crises

[4] World Economic Outlook, April 2020, International Monetary Fund: https://www.imf.org/en/Publications/WEO/Issues/2020/04/14/weo-april-2020

[5] Economic Impact of the COVID-19 on Africa, UN Economic Commission for Africa, Addis Ababa, Ethiopia, 13 March 2020, online at: https://www.uneca.org/sites/default/files/uploaded-documents/stories/eca_analysis_-_covid-19_macroeconomiceffects.pdf

[6] Given the required rapid evolution of government responses, this is likely to change swiftly from the date of this measurement, however.

[7] More than 60 Percent of the World’s Employed Population are in the Informal Economy, International Labour Organization, 30 April 2018: https://www.ilo.org/global/about-the-ilo/newsroom/news/WCMS_627189/lang--en/index.htm

[8] South African Department of Arts & Culture statistics 2011-2012, the latest available figures.

A significant part of holding leaders accountable in the Coronavirus disease (Covid-19) response is playing a watchdog role in how human rights are protected or trampled by elected leaders in Africa. Some countries have exhibited enduring respect for human rights and this continues under the epidemic response. Others, as you will read below, have been opportunistic and taken COVID-19 as a moment to secure power, suppress opposition and silence civil society.

Out of the 54 countries in Africa for which data is available, 13 of them (Burundi, Central African Republic, Chad, Congo-Brazzaville, Eswatini/Swaziland, Guinea-Bissau, Libya, Djibouti, Madagascar, Mauritania, Saharawi Republic/Western Sahara, Somalia and Tunisia) have instituted no measures to deal with the spread of the epidemic, according to the International Center for Not-for-Profit Law’s INCL’s) Covid-19 Civic Freedom Tracker^[1] but the other 41 countries (75%) have implemented a variety of measures ranging from a state of emergency to special Covid-19-related decrees. The INCL has no data for Comoros, Mauritius, São Tome and Príncipe, and Seychelles.

With the exception of Eswatini (Swaziland), all Southern African countries have implemented legal measures to cope with the spread of the pandemic. In all cases, freedom of assembly has been severely restricted with citizens confined to their homes, and only permitted to travel short distances in order to obtain food, medical assistance, or to deliver essential services. Public gatherings have been limited to less than 100 people, in some cases 50 and, in the cases of Zambia and Zimbabwe to five and two people, respectively.

Human rights activists, policymakers, philanthropists, and public health professionals should pay attention to whether a country’s official response to the novel Coronavirus disease is based on a special act of parliament – in other words, where the response has been scrutinized and endorsed by political parties not in power – or whether based on an order grounded in regulatory, including emergency, powers vested in various government ministries and departments. The rapid onset of the pandemic has seen numerous instances of contradictory rules being issued by different ministers – and also of officials on the ground, especially police, misinterpreting or exceeding their proper remit.

It is important to note that where national authorities overstep the mark in their application of emergency responses to Covid-19, or where civil servants exceed their powers, the people targeted as a result are very often marginalized and excluded populations: women and girls, lesbian, gay, bisexual, trans, and queer (LGBTIQ) persons, people who use drugs, sex workers, people who pass through prisons and other places of detention, migrants and displaced people, refugees, the elderly, the mentally ill, people living with disabilities indigenous people, civil society activists, journalists, and perceived political opponents. To these must be added, as victims of prejudiced Covid-19 responses, the economically excluded because the poor generally are rendered additionally exposed to the virus as a result of inadequate access to decent health-care and sanitary living conditions. Some of these communities have also been demonized by officialdom or sectors of civil society for supposedly spreading the virus.

Key areas of concern:

Press Freedom and Freedom of Expression

Several countries have instituted measures restricting press freedom and freedom of expression under the guise of stamping out disinformation or “fake news” relating to the pandemic and to the state’s response programme. While a number of these already had restrictive laws in this regard and have shut down civic spaces even further (Egypt, Zimbabwe, Morocco: for example, the Moroccan Minister of Culture, Youth and Sports has suspended the publication and distribution of print newspapers until further notice), it is very alarming that relatively open, democratic societies such as South Africa and Ghana have also seen fit to follow suit with punitive measures on freedom of expression.

Zambia’s ruling party has apparently used the outbreak of Covid-19 to settle political scores, closing down The Post newspaper and Prime TV; both media houses are perceived to be supportive of the opposition, and in the case of the television station, it was shut down for allegedly having refused to carry government Covid-19 announcements. In Tanzania on 20 April, journalist Ussi Hamad with the daily Daim a newspaper was suspended from work for six months for merely reporting on the pandemic; this came days after the Mwananchi daily newspaper had its online license suspended for posting a picture of President John Pombe Magufuli shopping, surrounded by people, which provided a debate on social distancing. Meanwhile, Egyptian authorities have expelled journalist Ruth Michaelson of The Guardian after she reported that Egypt has far more coronavirus cases than have been officially reported. In Ethiopia, a months-long internet shutdown in parts of the country aimed at curbing the Oromo separatist group has prevented millions of Ethiopians from accessing information about the pandemic.

Curbs on freedom of expression are keenly felt by artists and cultural workers who are either unable to make a living or travel to safe residencies as a result of lockdowns during the crisis. Also, such creatives are important interpreters of social realities for their communities and broader national societies, so any critiques they produce of state responses to the pandemic are likely to fall foul of emergency rules that curb free expression. Free press and expression and arts rights justice campaigners continue to monitor such issues.

Police Brutality

Reports of heavy-handed enforcement of the regulations, including, in some cases extrajudicial killings, by police, army, and security force personnel have been recorded in a number of countries. In South Africa, there have been eight deaths reported at the hands of the police enforcing the lockdown, and there have been many more instances of the police and army subjecting citizens to assaults and degrading treatment for allegedly being in breach of containment regulations.  Reports are also emerging of a similar pattern in Angola, Zimbabwe, Namibia, Nigeria, Kenya, the DRC, Senegal, and Uganda.

Prisons and refugee camps

Public health authorities have warned that prisons are one of the greatest risks for the spread of the virus because of the manner in which prisoners are kept in confined spaces. In Africa this risk is further exacerbated by the well documented overcrowding of prisons across the continent, but to date few African countries have released awaiting-trial prisoners or those incarcerated for minor non-violent offences. However, on 5 April, King Mohammed VI of Morocco pardoned 5,645 prisoners in a bid to curb the spread of the virus by alleviating overcrowding, though the prisoners were not released wholesale, but rather in phases based on factors such as their youth and conduct. This represents 7,05% to be released of Morocco’s reported incarcerated population of 80,000 (two of whom tested positive), and 10,200 warders (nine of whom have tested positive). Ethiopia has released 4,000 prisoners, while Cameroon has also announced a limited release of prisoners – excluding those accused of terrorism, separatism and other serious offences.

Amnesty International demanded that authorities in Sub-Saharan Africa “must take urgent action to protect people in detention from Covid-19 including releasing prisoners of conscience, reviewing cases of pre-trial detention, and guaranteeing access to healthcare and sanitation products in all facilities.”

Many of the same concerns relating to prisons can be applied to another form of unfree detention – that experienced by migrants in the continent’s massive refugee camps in countries as diverse as Chad, Uganda, Kenya, Ghana, Burkina Faso, Ethiopia, and Zambia. Because of rudimentary health and sanitation facilities, these camps, which often host tens or even hundreds of thousands of refugees, are exceptionally vulnerable to respiratory infections such as influenza and, if their residents are provided with inadequate health-care could become new epicentres of the pandemic. Most early results of pilot tests regarding the possible transmission of the Covid-19 virus via feces have proven negative, yet implementing Sustainable Development Goal 6,  access to water, sanitation and hygiene (WASH), as well as public campaigns for people to regularly wash their hands, will prove critical here. Sudan alone had 1.86 million internally displaced persons (IDPs) as of July 2019, and the African Center for Justice and Peace Studies (ACJPS) has called on both the authorities and separatist rebel groups to jointly under UN auspices come up with an action plan to ensure non-discriminatory inclusion of these displacees in health-care provisions during the epidemic, including access to adequate information on combating the spread of the virus.

Indigenous peoples

In Angola, Amnesty International has reported that NGO workers were assaulted and arrested by security forces when they attempted to deliver health information and essential hygiene products to San communities in the remote parts of Cuando Cubango province. In general, indigenous communities across the continent, from the San in the Kalahari to the Amazigh in Morocco’s Atlas Mountains, report that they have been neglected in the Covid-19 response, owing to their lack of resources, lack of access to basic healthcare, water and sanitation, their geographic remoteness, as well as institutionalised discrimination.

In fact activists and health care workers have been bemoaning the lack of guidelines for health-care personnel on how to continue standard care and visits to remote indigenous communities in the face of the epidemic, as visits to these communities might perpetuate an outbreak in these areas. Some hypothesize these communities may have lower resistance due to lower exposure to coronaviruses generally, which would make them additionally vulnerable to discriminatory health practices. The Indigenous Peoples of Africa Co-ordinating Committee, a network covering 22 countries, warned that while lockdowns appeared effective, they could not be imposed against indigenous peoples because of their nomadic lifestyles.

LGBTIQ communities

Communities such as the LGBTIQ community that are already marginalized and vulnerable due to a range of factors including poverty and discrimination, now face further challenges during the pandemic; many are in fact rendered even more at-risk due to the response of authorities under emergency regulations. A now well-known example is that on 29 March on the outskirts of Kampala, Uganda, when the police raided a shelter and arrested 14 gay men, four transgender women, and two bisexual men, charging them with breaking social distancing rules (set at a maximum of 10 people and since reduced to five); equal rights campaigners have countered that the arrests were motivated by homophobia and transphobia and not the emergency regulations.

Xenophobia

Concerning reports are emerging that several Southern African states (Botswana, South Africa, Zambia, and Namibia) are deporting hundreds of illegal Zimbabwean immigrants back to Zimbabwe under the guise of quarantine requirements. Given the history and continuation of human rights abuses occurring within Zimbabwe and a shortage of food, water and sanitation within the country, this is a serious issue that undermines the desired inclusiveness of universal access to health-care.

Conflict

Lastly, it worth noting that the pandemic is, in some parts of the continent, happening in a context of armed conflict. The pandemic is likely to exacerbate and fuel some conflicts: for example, Islamic militants have now (April 2020) launched a fresh offensive in northern Mozambique.

Summary

While many African countries have launched epidemic prevention measures, a few have taken the opportunity afforded by the necessary emergency response to the pandemic to achieve ulterior aims. Human rights abuses are occurring across a broad spectrum and these need to be monitored closely. Of particular concern are the economic effects of lockdown and other quarantine measures on economic development and social stability. If social unrest from hunger or disease occurs, there is a possibility of heavy-handed responses from various states. Africa’s governments need to be held accountable through active dialogue in this time of crisis with a broad range of stakeholders to ensure an inclusive health-care response is backed up by respect for universal human rights.

Footnotes:

^[1] Covid-19 Civil Freedom Tracker, International Center for Not-for-profit Law (ICNL), online at: https://www.icnl.org/covid19tracker/?location=&issue=&date=&type=

* We have not here differentiated between Somalia and the self-administered yet unrecognized region of Somaliland but are tracking responses to the pandemic under both administrations.

Governments’ response to COVID-19 has in most cases involved earmarking a significant percentage of Gross Domestic Product (GDP) – the standard measure of a country’s productive wealth – towards fighting the pandemic. Although this is only part of most governments’ broad-spectrum policy response to the disease, it is an important measure as it indicates governments’ level of commitment to responding to the coronavirus disease (COVID-19) pandemic. It must be stressed, however, that different governments face different levels of severity of the pandemic and different projections (depending on a wide range of conditions including the capacity of their health-care systems, the size, distribution and characteristics of their populations rendered vulnerable by poverty, HIV or other factors, and logistical difficulties in meeting essential needs in facing the crisis.)

Earmarking state funds to fight the pandemic has been done in one of two ways: either governments have increased their health budgets, or they have established specific anti-COVID-19 funds aimed at financing a broader response than health alone. It appears from the accompanying data, derived from the International Monetary Fund (IMF), that countries’ response is largely dependent on current budgetary funding as their responses usually focus on 3- to 12-month response plans. Based on the fiscal data, only two countries have estimated (but not yet committed to) the overall response cost to fight Covid-19, namely Togo and Republic of Congo. The differences of approach – budget increase or specific fund, intermediate-term or long-term costings – depends to a degree on considerations including but not only the amount of available foreign aid which can be thrown into the fight.

According to the UN Economic Commission for Africa (UNECA), although the impact of COVID-19 on Africa appears at this stage to be less dramatic, according to reports, than on Europe and North America,[1] the economic impact of the virus in Africa is “disproportionate,” because of its high trade vulnerability to import and export fall-offs due to the pandemic. The continental economy is expected to decline sharply from a 2019 growth rate of 3.2% to 1,8% this year, the loss equivalent to US$29 billion.[2] Predictions are that particularly hard-hit will be oil, tourism, and remittances from African Diaspora communities back to their home countries. In addition, foreign direct investment (FDI) is expected to decline, capital is expected to flee the continent’s markets, and those domestic markets will shrink as spending (on all but essentials) as well as spending-power (with job losses) declines. Also, inflationary pressures are expected to grow as supply-chain disruptions create shortages (including of food and pharma) and undermine market value-creation. Of particular concern, according to the UNECA analysis, is a likely increase in national debt as countries borrow to either fund their COVID-19 responses, or to fund stimulus response packages to subsidize flagging economies (another area that Accountability International is tracking).

These factors, along with tax holidays for individuals and businesses, will all negatively affect GDP – and thus the amount of money available to governments to direct to combating the virus. The case of oil-export-dependent countries is worth examining in a little detail. As the Organization of Petroleum Exporting Countries (OPEC) has attempted to stabilize falling oil prices caused by a fall in demand (caused by significantly reduced air and road travel) by slashing production to prevent a glut on the market, African oil producing member countries have followed suit – which means slashing their collective GDP by US$65 billion, UNECA estimates. But the effect of this on their economies differs depending on oil exports as a share of exports – and as a share of GDP.

According to the UNECA data, the top 10 oil producers in Africa in descending importance, based on 2016-2018 annual averages, are:

1. Nigeria at US$42,7 billion in oil exports
2. Algeria at US$33,9 billion
3. Angola at US$33,3 billion
4. Libya at US$15,5 billion
5. South Africa at US$9,2 billion
6. Egypt at US$6 billion
7. Equatorial Guinea at US$4,8 billion
8. Congo at US$4,2 billion
9. Gabon at US$3,2 billion, and
10. Ghana at US$3,1 billion.

Of these, the economy of Libya is likely to be hardest-hit by oil revenue losses – on top of the civil war it is experiencing – because while its share of exports is high (88.4%), oil exports’ share of its GDP is the highest of the top ten (62.1%), meaning its economy is poorly diversified and too oil-dependent. The top oil exporter that is least likely to be hard-hit is South Africa with oil exports’ share of total exports relatively low (10.8%) and their share of GDP very low (2.7%), giving it a more diversified economy which is more resilient to oil shocks. Regardless of export losses, however, most governments are protecting their health expenditure, as the IMF notes for Algeria: “In response to the oil price shock, authorities have announced their intention to lower current spending by 30 percent (8% of GDP or USD 15 bn), while keeping wages intact and protecting health and education spending.”^[3]

Despite declining GDP, FDI and other financial stimuli, however, African economies are expected to spend an additional US$10,6 billion on health this year to combat the novel Coronavirus. This is a mixed blessing: higher health-care expenditure is certainly needed to flatten the curve of the viral infection and mortality rates – but such massive unplanned expenditure can be expected to reduce spending on other important areas, even within the health sector, such as sexual and reproductive health and rights (SRHR), another key response indicator that Accountability International is assessing to enable clear, evidence-based COVID-19 policy debates.

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Footnotes:

[1] It is a little too early to say, but the reported lower incidence of the virus in Africa is probably related to a range of factors including the later transmission of the virus to African countries which enabled the authorities to respond with earlier lockdowns and positive-case detection than in Europe and North America.

[2] Economic Impact of the Covid-19 on Africa, UN Economic Commission for Africa, Addis Ababa, Ethiopia, 13 March 2020, online at: https://www.uneca.org/sites/default/files/uploaded-documents/stories/eca_analysis_-_covid-19_macroeconomiceffects.pdf

[3] Policy Responses to Covid-19, International Monetary Fund, Washington DC, USA, data as of 10 April 2020, online at: https://www.imf.org/en/Topics/imf-and-covid19/Policy-Responses-to-COVID-19#A

Please note: This is an updated version of the original Scorecard Datapoint, published on 15 April 2020 and available here.

On the Frontlines: Nurses, Doctors, and Midwives

It bears restatement that nurses, midwives, and doctors – as well as other emergency and medical personnel from ambulance drivers and paramedics to lab technicians, clinic administrators, and hospital porters – are in the frontlines of the fight against COVID-19. Far more so even than in times of outright war, these personnel across medical disciplines and across the continent are involved in an unprecedented, universalized battle to preserve life. Especially for first responders and first carers, recognition has been widely given that they are undertaking huge personal risks – risks that they might take home to their families – in conducting virus testing, assisting with preventive measures, and health-care of the ill and vulnerable. Maintaining the health of frontline healthcare workers is also key to maintaining the health of each country, particularly in the light of asymptomatic carriers being key to the spread of the virus, and the fact that around 41% of COVID-19 cases in Wuhan occurred through hospital-related transmission.[i] The protection of healthcare workers is a significant factor not only in controlling the pandemic but also ensuring ongoing care for those infected, as well as those experiencing non-coronavirus related ill health.[ii]

Personal Protective Equipment

Ensuring that healthcare workers are adequately protected requires the availability of adequate masks and disposable gowns – the lack of which in many countries received much publicity. As crucial, and less spoken of, is the need to ensure that all healthcare workers showing symptoms have access to rapid response tests which have a 100% ability to confirm negative cases within 15-45 minutes depending on the type of test used.ⁱⁱ This needs to occur within regulations that allow administration of these tests even in the absence of symptoms, making the regulatory environment for testing as important as the provision of the tests themselves. This would enable healthcare workers to serve immuno-compromised and higher-risk patient groups. It is also important to note and take seriously the impacts of prolonged use of protective equipment such assurgical masks or N95 respirators on the health of healthcare workers. Studies show healthcare workers experiencing excessive sweating around the mouth, difficulty in breathing, increased acne and irritable nostrils which can result in poorer adherence to safety protocols and greater susceptibility to infection.[iii] Factors leading to increased infection of healthcare workers also include long-term exposure to significant numbers of infected patients, pressurised working environments, and a lack of rest.[iv]

Mental Health

The health risk to frontline healthcare workers is multidimensional, with mental health being a key component. Frontline healthcare professionals face difficult decisions under heightened moral pressure during the pandemic. They are faced with the requirement to balance their own psycho-social needs with those of patients, as well as their duty to patients as against their duties to their loved ones – as well as challenges in providing care to those needing critical care in resource-constrained environments.[v] This places medical healthcare professionals at risk of moral injury (actions or inactions which violate someone’s moral or ethical code resulting in psychological distress), which results in experiencing negative self-image or negative attitudes about colleagues, and intense feelings of disgust, guilt or shame[vi]. Medical students exposed to situations for which they feel unprepared such as pre-hospital emergency care have already been shown to experience this.[vii]

On the one extreme, moral injury creates greater risk of mental health challenges such as post-traumatic stress disorder (PTSD), depression or suicidal tendencies – yet on the other it can alternatively lead to what is termed post-traumatic growth, which is increased mental resilience, self-esteem, positive perception and strengthened values after experiencing highly stressful and difficult situations.[viii] Whether one develops mental health challenges or post-traumatic growth is shaped by the type of support received during, as well as before, during and after challenging situations. This makes the provision of early support as well as frank and adequate preparation for job-related stresses essential, as is the integration of best practice on mental health issues into clinic and hospital staff care protocols. This is particularly needed by healthcare workers in routine support processes, and requires supportive supervision.[ix] Proper after-care, through providing resources that allow for maintaining spaces for reflection, learning, and processing once times of extreme stress is over, is also key to avoid long-standing psychological damage to essential healthcare staff.[x] These initiatives need to be implemented while cognisant of socio-demographic variables that are associated with increased negative mental health outcomes[xi] (like anxiety, insomnia and depression) such as gender, age, profession, and department of work.

Gender

The gendered impacts of the virus are particularly relevant. Not only is being female and living with family members associated with increased mental health risks,[xii] but an overwhelming 70% of the global healthcare workforce is female.[xiii] Despite this, women hold only 25% of senior roles in the sector, and perform lower-status and underpaid – or even unpaid – roles.[xiv]Healthcare workforce demographics mean greater numbers of infected healthcare workers are women, and greater percentages of healthcare workers losing their jobs due to facility closures under COVID-19 are female. The healthcare risk associated with living with family is unsurprising, as added caretaking responsibilities are an additional stress factor.[xv] In dual-parent homes, school closures increase the responsibilities of the primary caregiver, and the burden of unpaid care tends to fall on women. This is compounded by COVID-19 where traditional support systems such as grandparents or friends are disrupted by social distancing, and social stigma against healthcare workers during the pandemic have in some instances resulted in a reluctance to babysit for medical professionals.[xvi]

It is thus essential to have a gendered understanding of the pandemic to ensure effective pandemic response particularly for healthcare workers.[xvii]Current practices such as the widespread male-centered design of Personal Protective Equipment (PPE) are manifestly illogical as they put the disproportionately female healthcare workforce at even greater risk as female healthcare workers deal with poorly fitting face marks, creating a greater need to remove and readjust face masks more often during long shifts.[xviii] The present situation in which healthcare is delivered by women who suffer disproportionate negative impacts under male leadership[xix] is unjust and untenable. This is relevant as well for society as a whole, with data from initiatives such as the South African Compensation Fund showing an overwhelming 80% of applications from women,[xx]hinting at the disproportionate gendered impacts of the pandemic. A gendered rather than gender-neutral approach is thus key to response and recovery efforts.

Africa’s Healthcare Brain-drain

We need to especially stress that in this “Year of the Nurse and Midwife” – declared by the WHO in honour of Florence Nightingale, the founder of modern nursing practice – that it is these medical practitioners on whose shoulders the burden of care initially and predominantly falls. About 50% of the global health workforce providing primary direct care in hospitals are nurses,[xxi] with data from countries like South Africa showing nurses as having the highest infection rates.[xxii] This alreadycritical situation has been exacerbated by a brain-drain of medical professionals out of Africa, caused by a complex set of factors including pull (better remuneration abroad) and push (poor equipment in African treatment centres) elements. Africa as a whole has, according to the World Health Organization (WHO), “24% of the [world’s health-care] burden but only 3% of health workers commanding less than 1% of world health expenditure. The exodus of skilled professionals in the midst of so much unmet health need places Africa at the epicentre of the global health workforce crisis.”[xxiii] This situation is exacerbated in that the remaining 3% is divided between the public sector, and the large private sector health system across the continent, which according to the International Finance Cooperation (IFC)[xxiv], delivers about half of Africa’s health products and services.  The novel Coronavirus epidemic has vastly exacerbated the danger to populations in the majority of African countries that have a critical shortage of health-care providers.

Staff Shortages and Task Transfer

The ratio of nurses and midwives per head of population given in the accompanying table is all the more important given the increasing practice of “task transfer” in which nurses have taken on specific medical interventions normally reserved to doctors alone. Task transfer has been driven both by necessity and by the evolution of health-care policy in different environments. In Africa, where the number of physicians per capita falls well below the global average of 14 doctors / 10,000 people in all but three countries (two of which, Mauritius and Seychelles, are small island states), it has often been by necessity that nurses, particularly in remote rural clinics and even many urban hospitals, have taken on some of the primary medical tasks of junior doctors.

Many countries’ health-care policies attempt to forestall the burden of referral of patient cases to hospitals by doing disease management at nurse-run clinic level. The search for ideal policy frameworks guiding the best distribution of medical resources has also driven task transfer. As noted in a 2019 European Commission study recommending evidence-based task transfer, “Tasks can be shifted from health workers to patients and their carers, to machines, and to other health workers. Where these shifts have been evaluated, they often, but not always, are associated with outcomes that are as good or even better than with the status quo. However, the study warned, “the results are often context dependent, and it cannot be assumed that what works in one situation will apply equally to another.”[xxv]

So while most of Africa has a general pattern of critically low medical doctor numbers, for nurses and midwives, the patterns are more differentiated. Still, only two countries (Libya and South Africa), meet or exceed the 2015 global average of 3.42 nurses or midwives / 1,000 people. Given task transfer and the dangerous lack of physicians, this is the professional layer that will need to be the focus of the AU’s African Task Force for Coronavirus (AFTCOR), particularly on the first three of its six technical areas of focus:

1. Surveillance, including screening at points-of-entry;
2. Infection prevention and control (IPC) in healthcare facilities;
3. Clinical management of persons with severe COVID-19 infection.

The existence of dual public-private healthcare systems in many countries also raises additional questions in the most effective and just ways of enlisting the assistance of private healthcare workers during the pandemic in the first place. This is particularly pertinent in light of the lack of cross-subsidisation from privatized healthcare serving (usually low-risk) persons who are healthy and wealthy, to the (usually high-risk) sick and impoverished served by the public sector. For example, in South Africa voluntary health insurance makes up 42% of total health expenditure – the highest percentage globally, for a scheme covering a mere16% of the population, leading to inequitable healthcare access among different socio-economic and racial groups.[xxvi] Efforts towards ensuring a coordinated national health response to the current pandemic need to be aware of the evidence that the countries worst affected by Ebola had in the past worryingly been directed to prioritize privatization and deregulation over developing strong public health systems.[xxvii] As such, ensuring the labour rights of healthcare workers are respected, as well as maintaining attractive conditions of employment while engaging in human rights based strategies to bridge the gap in healthcare service created by privatization is paramount.

Labour and Other Rights

Healthcare workers also need not only an increased focus on their socio-economic context, but also a safeguarding of their enjoyment of civil and political rights. During the pandemic, many governments have intentionally refrained from disclosing information or delayed doing so, misleading the public and promoting the spread of false information. This has been compounded by the gagging and censorship of healthcare workers in many contexts, preventing them from communicating directly with the public themselves. It is the very acts of whistle-blowing that resulted in the first alert of an emerging pandemic in China by Drs Fen and Wenliang,[xxviii] and many other instances of the same that have proven a guarantor of transparency as well as the enjoyment of the right to access to information for the general public. Policies and practices that guard against censorship, disciplinary action, and dismissal of whistle-blower healthcare workers are therefore key in ensuring an enabling working environments that elevate medical ethics above political considerations.

Conclusion

To conclude, effective approaches to frontline healthcare workers during the pandemic need to be holistic, looking at multiple dimensions of impacts on medical professionals including on their physical and psycho-social wellbeing. They need to take into account the impact of societal stigma and discrimination emerging against healthcare workers during the pandemic, as well as practical challenges like staffing and PPE shortages. A gendered lens is essential, and central to developing responses that take into account the disproportionate impact of these issues on women, who are overpoweringly at the front of pandemic response on multiple fronts.

Medical Doctors Data

Nurses and Midwives Data

***

Caveat: Accountability International is critically aware that the statistics that are presented to the Africa CDC or other regional/continental/global organizations on which we base our scorecard grading are not without some problems and can thus not always be taken at face value. Firstly, on a country-by-country basis, we need to have an understanding of the robustness of each country’s reporting mechanisms (are they adequately funded, comprehensive, and statistically sound?). Next, we need to recognise that in rare cases, the temptation of governments to improve their public image by under-reporting the impact of the pandemic may prove too strong: this is clearly the case with Tanzania that dangerously ceased reporting on 31 May 2020, but there may be other less obvious examples that involve under-reporting rather than a total refusal to provide data. Lastly, a pre-existing lack of data, particularly on key populations, undermines an adequate understanding of the impact of the pandemic on the most vulnerable and marginalized.

Footnotes:

[i]        F Anelli et al ‘Italian doctors call for protecting healthcare workers and boosting community surveillance during Covid-19 outbreak’ (26 March 2020) BMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1254.

[ii]        D Chang et al ‘Protecting healthcare workers from subclinical coronavirus infection’ (2020) 8 Lancet Respir Med  doi:10.1016/S2213-2600(20)30066-7. Pmid:32061333.

[iii]       PK Purushothaman et al ‘Effects of Prolonged Use of Facemask on Healthcare Workers in Tertiary Care Hospital During COVID-19 Pandemic.’ Indian J Otolaryngol Head Neck Surg (15 September 2020) https://doi.org/10.1007/s12070-020-02124-0.

[iv]       J Wang et al. ‘Reasons for healthcare workers becoming infected with novel coronavirus disease 2019 (COVID-19) in China’ Journal of Hospital Infection at 1 https://doi.org/10.1016/j.jhin.2020.03.002

[v]       N Greenberg et al ‘Managing mental health challenges faced by healthcare workers during Covid-19 pandemic’ 368 BMJ 2020 at 1211.

[vi]       See note v.

[vii]      E Murray et al ‘Are medical students in prehospital care at risk of moral injury?’ (2018) 35 Emerg Med J at 590-4. doi:10.1136/emermed-2017-207216. 

[viii]      See note v.

[ix]       See note v.

[x]       See note v.

[xi]       M Spoorthy et al ‘Mental health problems faced by healthcare workers due to the COVID-19 pandemic–A review’ (June 2020) 51 Asian Journal of Psychiatry, https://doi.org/10.1016/j.ajp.2020.102119.

[xii]      EH Alzaid et al ‘Prevalence of COVID-19-related anxiety among healthcare workers: A cross-sectional study.’ 9 J Family Med Prim Care at 4904 (September 2020).

[xiii]      I Miyamoto ‘Covid-19 Healthcare Workers: 70% Are Women’ (May 2020) Security Nexus Perspectives https://www.jstor.org/stable/resrep24863?seq=1#metadata_info_tab_contents.

[xiv]     See note xiii.

[xv]      See note xiii.

[xvi]     See note xiii.

[xvii]     See note xiii.

[xviii]    A Arbaud ‘Female Health Workers and COVID-19: Gender Disparity in a Time of Global Crisis’ (May 2020) https://www.thet.org/female-health-workers-and-covid-19-gender-disparity-in-a-time-of-global-crisis/.

[xix]     World Health Organization, Delivered by Women, Led by Men: A Gender and Equity Analysis of the Global Health and Social Workforce (Geneva: WHO, 2019) https://apps.who.int/iris/bitstream/handle/10665/311322/9789241515467-eng.pdf?ua=1.

[xx]      See note xxii.

[xxi]     S Liu ‘Protection Procedures and Preventions against the Spread of Covid-19 in Health Care Settings for Nursing Personnel – Lessons from Taiwan’ (October 2020) Australian Critical Care https://doi.org/10.1016/j.aucc.2020.10.006.

[xxii]     New Frame, ‘South Africa: COVID-19 Roundup – Women, Health Workers Hardest Hit’ (July 2020) https://allafrica.com/stories/202007100832.html.

[xxiii]    World Health Report, World Health Organization, New York City, USA, 2006, online at https://www.who.int/whr/2006/overview/en/

[xxiv]    L Joseph ‘Health care in Africa: IFC report sees demand for investment’ https://www.ifc.org/wps/wcm/connect/news_ext_content/ifc_external_corporate_site/news+and+events/healthafricafeature.

[xxv]    Task Shifting and Health System Design, Report of the Expert Panel on Effective Ways of Investing in Health, European Commission, Luxembourg, 2019, online at https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/023_taskshifting_en.pdf

[xxvi]    TJ Sehoole ‘COVID-19: Pandemic burden in Sub-Saharan Africa and the right to health – The need for advocacy in the face of growing privatisation.’ (2020) 12 Afr J Prm Health Care Fam Med 2476. https://doi.org/10.4102/phcfm.v12i1.2476.

[xxvii]   RN Pailey ‘Ebola outbreak exposes large gaps in financing adequate healthcare in West African countries.’ 82 Dev Viewpoint at 1–2,https://www.soas.ac.uk/cdpr/publications/dv/file96579.pdf.

[xxviii]   V Abazi ‘Truth Distancing? Whistleblowing as Remedy to Censorship during COVID-19.’ (6 May 2020) 11 European Journal of Risk Regulation at375-381. doi:10.1017/err.2020.49.