The COVID-19 pandemic has subsided though the World Health Organisation is yet to officially declare it ended. Most countries have removed covid-19 pandemic restrictions and returned to pre-pandemic processes after the world’s economic and social activities were crippled and held to a standstill for more than two years. There are still lingering unanswered questions in peoples’ minds concerning covid-19 pandemic. Why was the effect very mild in Africa, especially in West Africa? The prediction of public health experts using different algorithms and models was that Sub-Saharan Africa would suffer the most deaths because of poor infrastructure and a shaky and underfunded healthcare system. These areas are already struggling with malaria, tuberculosis, polio, malnutrition, and a host of other tropical diseases. And the addition of covid-19 will stretch the weak healthcare system to its fullest resulting in a covid-19 Armageddon. According to WHO, most African countries’ health systems do not have the capacity to monitor the spread and contact tracing and a countrywide community screening and testing. There is a shortage of health personnel and a lack of or limited emergency facilities to manage COVID-19 patients who are critically ill. The expectation was to see the streets littered with corpses. But it never came to pass. There have been different suggestions as to why Sub-saharan African countries survived the brunt of Covid-19 when compared with other wealthier and more advanced nations with better healthcare systems and infrastructure. This debate has divided scientists within and outside Africa and people have taken sides to justify why there was a low rate of COVID-19 infections, hospitalisations, and deaths in Sub-Saharan Africa including Nigeria. But either side of the aisle has not been able to convince or explain beyond all reasonable doubts what happened in Africa with covid-19. It begs to look for somewhere else for answers to the ‘African paradox’. That brings us to PRAYERS and belief in God. Since the outcome appears to have defied most scientific explanations, then maybe the prayers of the people may not have been in vain. This article will use Nigeria as an example of a country in West Africa and compare her data with that of the United States.
How far have we come from the pandemic? Based on Worldometers data as of October 8, 2022, there are about 626,233,155 diagnosed coronavirus cases worldwide with 6,559,992 deaths. For the same period, Nigeria recorded 265,741 cases and 3,155 deaths while the US had 98,523,168 cases and 1,087,655 deaths. For reference, the US population is 331,893,745, and Nigeria 206,139,587. A comparison was made of Nigeria’s data with that of the US using case fatality rate, used to measure the severity of a disease and mortality rate which is the number of people that died from the disease. The case fatality rate for Nigeria is 1.2% while that of the US is 1.1%. The mortality rate in Nigeria is 0.002%, USA 0.33%. It can be deduced that more people died from the disease in the US than in Nigeria, but the severity was about the same. Most of the reports that the low mortality rate of covid-19 in Sub-Saharan Africa had been dismissed as anecdotal but there is a common saying that numbers don’t lie.
In a discussion with Ms. Ndidi Nwangwu-Ike, an epidemiologist in, the Division of HIV Prevention at the CDC, who visited Nigeria recently, she was surprised that the havoc wasn’t as bad as projected. According to her, many Africans may be immune already as they’re dealing with multiple airborne diseases at any given point. Also, many do not get tested- hence low reported cases. There is a lack of a robust surveillance system in Nigeria. Another factor is that the median age in most sub-Saharan Africa is low, Nigeria is 18 years. The data shows that these are not the ones that are typically hit hard with Covid. However, in her opinion, most of the cases both the sick and the dead were under-reported. It is believed that the people who die in their homes are not accounted for and not recorded in the government’s official document. That is the stand of most public health experts. It is a common belief that the number of cases was under-reported because of a shortage of test kits for SARS-CoV-2, the official name for the virus that causes Covid. Also, no standard electronic hospital and laboratory information systems. Thus, the number of cases cannot be tracked correctly. Ms. Nwangwu-Ike also shares the same speculations with other epidemiologists that the low mortality rate in Nigeria was because of the relative youth of Nigerian populations. The median age in Africa is about 18 years, while that of Europe is 43 and 38 in the United States. About 70% of the Nigerian population is under 30 years old. And covid-19 is reported to have a more adverse effect on older people. The risk of developing dangerous symptoms and negative outcomes increases with age. This means that fewer people in Nigeria when compared with the US will have complicated covid-19 symptoms. Most of the infected youth are asymptomatic. And thus, the reported low number of cases in Nigeria is maybe because WHO/CDC protocol did not include testing of asymptomatic patients at the onset of the pandemic. It was later that asymptomatic people were tested as part of the requirement for international travels. And even at that, there was no spike in the number of people infected in Nigeria. And there were no dead people littered on the streets of Lagos or Umuahia or even Item in Bende Local Government of Abia state.
To solve the puzzle, environmental factors were said to have played a role. It is suggested that covid-19 does not thrive well under high temperatures. Nigeria’s weather is mostly summer all year round. Covid-19 like other flu viruses spreads most during cold winter weather. Also, in Sub-Saharan Africa, people spend more time outdoors which reduces the chances of spreading the virus among people in proximity. This argument is acceptable for people living in sparsely populated villages. However, it is a different case for people living in overcrowded cities like Lagos. In the typical “face me I face you” apartment blocks, you may have a family of six in one room. This increases the likelihood of transmission. It was scary when Nigeria joined in the WHO’s recommendation for a stay-at-home policy. If the virus was in circulation in Lagos as was speculated and virulent, the stay-at-home policy would have been counterproductive. However, we cannot discountenance the God factor, maybe God heard the prayers and the supplications of His children and helped them to beat the odds.
As the debate ensured, Dr. Charles Okeahalam and his group from the School of Economics and Finance, Faculty of Commerce, University of the Witwatersrand, Johannesburg, South Africa suggested that early initiation of breast-feeding conferred protection against COVID-19 infection in sub-Sharan African populations. Their assumption is not farfetched because other researchers have associated breastfeeding with protection against chronic adult diseases. In their opinion, the common practice of initiating breastfeeding in African communities may have had some prophylactic effect against Covid-19 and may have also prevented people from developing severe cases of Covid-19.
A plausible reason that resonates with most experts is that countries with improved public transportation infrastructure had more cases. Public transportation facilitates increased movement and contact with people. Most cities with tourist destinations had more cases. That is why Lagos had the most cases in Nigeria because it received more people from different countries. At a point in the pandemic, Lagos airport became a hub for people traveling from Europe to the United States since direct flights were not allowed from Europe to the US. This further exposed Nigerians to the potential carriers of the virus from Europe.
An interesting angle was brought into the discussion; Nigeria’s healthcare woes or misfortunes are thought to be a blessing in disguise during the Covid-19 pandemic. It is believed that previous exposures to different diseases helped the population to develop immunity against the virus. Some scientific studies have tried to establish cross-reactivity between covid-19 and other coronaviruses, Lassa fever, Ebola viruses and even parasitic diseases such as malaria, river blindness, and filarial worms. The conferment of immunity against covid-19 has been interrogated further due to the case of India. India, like Nigeria, is bedeviled by malaria and other coronaviruses but the Delta variant hit India harder than it did Nigeria. So, it became doubtful if co-infection with malaria can protect anyone from covid-19. Nigeria was said to have tapped into lessons learned from previous public health responses. The recent Lassa and Ebola outbreaks helped Nigeria to know how to respond to a public health emergency. The previous experience in handling Ebola helped Nigeria to develop a response system that may be different from the developed world. So, it may be a lame argument to state that Sub-Saharan Africa does not have the infrastructure to respond to covid-19 pandemic. At the outset, the public health officials knew what to do as they have been primed by the ebola epidemic experience. When the Western world was still grappling with how to respond, Sub-Saharan African countries already set up their surveillance system in place.
It is also speculated that some medications used for the treatment of common diseases in Nigeria could have proffered prophylactic protection against Covid-19. Especially chloroquine used to treat malaria and ivermectin for river blindness (onchocerciasis) and other filarial worms in Nigeria. Ivermectin is even explored as a possible drug for covid-19 treatment. Some clinical trials are ongoing for some brands of ivermectin. Mectizan is the brand of Ivermectin approved by the WHO and in use in Nigeria since 1988 for the treatment of river blindness. Other brands of Ivermectin approved for human use are Stromectol and soolantra. Ivercor is a brand of ivermectin undergoing clinical trials for the treatment of Covid-19. River blindness elimination strategies in Nigeria include diagnosis, mass drug administration (MDA), health education, and black fly vector control. But the strategy of interest is the mass drug administration with ivermectin. About three-quarter of the Nigerian population is under the MDA program. Ivermectin is given to the population at risk annually to kill the parasite larvae. This MDA with the ivermectin program in some parts of Nigeria is linked to protection against covid-19. In my presentation “Ivermectin Treatment and the Spread of Covid-19 in Nigeria,” at the 16th International Symposium on Metal Ions in Biology and Medicine, Nehru Science Centre, Mumbai India on November 30th, 2021, it was demonstrated that ivermectin may not have played a significant role in the covid-19 disease outcome in Nigeria. The study compared the morbidity and fatality rates of covid-19 between states that are actively participating in the Ivermectin mass drug treatment program with the states that are not. There was no significant difference between the states treated with ivermectin and those not treated. This suggests that ivermectin may not be a serious factor in the low fatality rate and low morbidity rates of covid-19 in Nigeria. Further exploration of the Nigerian data has shown that there are a lot of other factors to could have affected the outcome of the comparison between the MDA and non-MDA states. These factors are to be accounted for to get a more reliable result. For example, there is a high movement of people from the MDA areas to non-MDA areas, observations of non-pharmaceutical Covid-19 safety protocols (hand washing or use of hand sanitizers, and wearing of facial masks), and use of antimalarial drugs (such as chloroquine), age, sex, and underlying comorbidities. Thus, the epidemic in Nigeria has no pattern and several factors could have impacted morbidity and fatality rates. However, more studies will be required to make further conclusions as testing coverage and data collection ability need to be improved.
The first time I shared the idea with some people that maybe prayers helped people in Nigeria to survive, I was asked if people in South Africa did not pray enough to be spared from Beta, Delta, and Omicron variants. Everyone agreed that the first wave had a minimal effect on the entire of Africa. Also, India suffered the same fate as South Africa. Does it mean Nigerians pray more than South Africans or that God loves Nigerians more? I don’t have that answer but the majority of Nigerians are religious. India, South Africa, and the US do not spend as much time at worship places as much as Nigerians. Nigerians even have churches in their homes! According to Pew Report, Nigeria has the highest number of Christians in Africa. Over 80 million Nigerians are Christians. Based on World Christian Database (WCD), 46.3% of Nigerians identify as Christians, 46.2% as Muslims, and 7.2% as ‘ethnic religions.’ However, the ratio of Muslims to Christians in Nigeria according to the World Factbook by the CIA is estimated to be 53.5% Muslim, and 45.9% Christian. Nigeria has the highest number of Muslims in West Africa. So, these religious people prayed assiduously, and probably their prayers worked. Well, another person argued that it could be that God is merciful because he knows that Nigerians cannot deal with such a pandemic as this. According to her, Nigerian society simply cannot deal with many of the measures that are encouraged to curb Covid. For instance, there is no personal space, just not enough space to allow for social distancing. Also, poor sanitation poses a major issue. People do not wash their hands in Nigeria that often and even if they want to, there is limited access to clean/potable water. There was a limited supply of hand sanitizers and facemasks. For those that believe, God is merciful and either way has answered the prayers. After all said and done, the prediction of Covid-19 Armageddon did not come to pass. There were no corpses on the roads and the emergency rooms were not filled with critically ill covid-19 patients. The God factor could be the most plausible explanation of the ‘African paradox’, a narrative that the pandemic was less severe in Africa than in other parts of the world.
Although Nigeria and indeed other sub-Saharan countries have somehow dodged the bullet from covid-19, there is no doubt that the pandemic gave an opportunity to observe the level of preparedness and capability of the healthcare system to respond to emergencies when compared with other parts of the world. There are noticeable gaps that need improvement in Nigeria’s healthcare system. Funding for the system is paramount and there is a need to invest more in healthcare capacity building, infrastructure, and disease surveillance. Nigeria needs to create and equip more public health laboratories and introduce a reliable national laboratory information system to keep track of diseases of public health importance. There is more work for the Nigeria Center for Disease Control and the federal ministry of health to do.
…Dr. Udensi K. Udensi is a Clinical Laboratory Scientist/Public Health personnel writing from Seattle Washington, USA