By Albert Roca. These notes are based on the recognition of the uncertainty of the international expert community on the spread of COVID-19 in Africa and on the ways of reacting to it. The objective is to present the actors and actresses involved with a simple starting table on the current consensus of the scientific community in this regard, as well as offering and requesting the continued collaboration in research that such uncertainty demands.

Although the evolution of COVID19 in Asia, Europe and the United States has allowed us to learn a lot and quickly about SARS-Cov2 and how to minimize the harm it can cause in humans[1], it must be recognized that we still know less than we do not know and that many of these learnings are not automatically applicable to other regions of the planet. I would like to draw attention to the perceptible differences in the countries south of the Sahara. And to do so from the agreements, always relative, of investigation, distancing myself from the more or less well-intentioned “Cassandra’s syndrome” that many media and not a few scientific and professional seem to claim in order to conjure such ignorance: experience shows that the harshness of the messages or the recourse to alleged and never verified hyperbolic figures of suffering (as, for example, repeated announcements over the past two decades of possible millions of deaths by food alert systems, in Ethiopia or the Sahel) have not increased either investment or solidarity flows in Africa.

The analysis of the combination of ecological, demographic, socioeconomic and cultural singularities is leading some scientists^[2] to question for the continent the automatic adoption of the two main models of reaction to Covid19, at least, as they have been put into practice up to now^[3]: on the one hand, critical voices discourage general confinement because its foreseeable effects on the socioeconomic fabric suggest a negative final health balance; on the other hand, they announce that the massive detection and medicalized isolation of infected people are not feasible at the national* level, given the healthcare limitations of the national health systems (NHS) in the continent.

Consequently, specific solutions and strategies would be required, “tailored” ^[4] for African societies, very diverse, even sharing singularities. This attitude implies promoting the association of research with intervention in the entire reaction against Covid19; not only virological research, but, perhaps above all, this one focused on African social factors and potentials in the epidemiological response.

Is this questioning of Covid19’s dominant models of containment and the consequent new demand for research reasonable? I think so. The interpretations that question the viability south of the Sahara of these hitherto dominant models not only appears more coherent under the light of the data about the pandemic that we have at the moment, however partial can they be, but they are also more consistent with what we do know about health in sub-Saharan Africa, beyond international emergencies (PHEIC since 2009), but certainly including the 2014 Ebola outbreak learnings. Many observers consider that this knowledge is being underused, with the following risk of promoting again, as in the past, strategies that involve diverting current scarce health resources, practically all of them essential in the region’s shortage situation, or accentuating external dependency, something that has historically weakened African healthcare systems.

Incorporating these critical interpretations into the programs of all the agents involved, from political managers to researchers or members of civil society, would allow for a realistic view of the unique potentials and deficits of African societies, with the aim of optimizing the application on the continent. of the knowledge accumulated by WHO and countries with experience in managing Covid19.

Among the African ecological singularities, climatic and demographic features have been mainly related to Covid19. The vast majority of the population south of the Sahara lives in the intertropical region. Despite some premature denials, the available data suggests that the climate of this region could prove to be unfavorable to the reproduction of SARS-CoV2, so the morbidity, the rate of contagion and mortality could be significantly lower than those observed in the tempered strip^[5]. Again, this clue, although not proven, fits with previous information regarding influenza or other coronaviruses, however incomplete^[6]. While it is true that the prevalence of respiratory diseases (the other major risk factor for SARS-CoV2 infections) is poorly understood in Africa and could be higher than the few reports reflect^[7], not to mention the common existence of other debilitating conditions associated with poverty, it also seems more than likely that these factors accumulate in the relatively rare elderly or in young children, one of the groups most targeted by selective primary health care programs (maternal and child health), so prevalent in Africa in recent decades. Consequently, it does not seem prudent to rule out that sub-Saharan climatology could be a relevant factor in “flattening” the Covid19 propagation curve, constituting a necessary study horizon.

With regard to demographic singularities, a crossroads between social and natural factors, the most important is the youth and dynamism of the population pyramid, diametrically opposed to that of the most affected societies in Europe and Asia[8]; the second, the lower number of long distance travelers in sub-Saharan Africa, specially coming and compared to the most affected areas, a flow that has been even more limited with the fall in transport and the blockages of routes triggered by the declaration of the pandemic. Given that the virus seems much less active among young people and children^[9], as well as given the absence of institutions that promote the daily concentration of elder (few elderly homes as those that have become true « traps » in Spain, for example), it is expected that the African demography will be another flattening factor of the Covid 19 spread curve.

The anticipation of the possibility of a slower growth of Covid19 in Africa does not lead, nor does it want to lead, to inaction, but it does allow modulating social alarm and stimulating the association of empirical research in strategies designed for different African scenarios[10]. This modulation is a key factor to which I will return. It should be remembered that it is the attempt to avoid the collapse of the health system, in fear of an abrupt increase in demands, particularly for patients hospitalized and in the ICU, which justifies the adoption of measures as costly socioeconomic and psychosocially as confinements or massive detections[11]. Thus, the ecology of sub-Saharan health allows us raise doubts about doubt the avalanche pattern in Africa and, therefore, about the usefulness of generalizing confinement patterns.

This forecast reinforces those derived from socioeconomic singularities that, as I have already pointed out, disallow the mimetic application of the models of general confinement and mass detection^[12].

The first, the great confinement, is not feasible due to the high percentages of the population that live daily, from agriculture, small urban jobs, local commerce …, populations that must resort each day to interpersonal exchange and reciprocity networks in the face of market hostility, the absence of state-guaranteed services and the well-known limitations of international cooperation. The key piece is the small size of the African states that should regulate all these flows. The absolutely insufficient administrative apparatuses bequeathed by colonization have been under enormous pressure since the late 1970s to reduce or freeze their budgets and potentials. Sustained growth in many African economies since the mid-1990s has not significantly altered this deficit, largely due to debt-related commitments or the flow of investment and capital. It is unrealistic, if not cynical, to think that, in a crisis such as that caused by a health closure, African states would be able to put in place exceptional and effective measures to support the unemployed or the sick. The unsustainability of the confinement model is already evident in those pioneering countries in its implementation, such as South Africa or Rwanda; On the other hand, it is very difficult to establish how far partial confinements go in Madagascar (Antananarivo and Toamasina) or Nigeria (Lagos), Ghana or Kenya, or to what extent the “leaks” of the insulation could make them more flexible and easier to apply.

Then, if the impossibility of supporting the confinement were to provoke massive acts of disobedience, the effective inability of the institutions to enforce it -due to the meagerness of their means- could easily degenerate into “exemplary violence” on the part of the state. Many voices have alerted to a possible upswing in authoritarianism in global society, not just in Africa. A rebound justified by a new categorical imperative, based in turn on the undisputed alibi of health: thus, the passage of international health (displayed since the creation of tropical medicine at the end of XIXth century to the MDGs), and its shameful health frontiers, to global health for all (announce in 1978 in Alma Ata but formalized with the SDGs) might have a dark side. But perhaps it is in Africa where the risks of materializing this dystopian perspective seem more immediate and worrying. The option of economic violence through the imposition of fines – the first negative reinforcement, more or less legitimate, of the model in Europe and Asia – is non-existent when the bulk of the most affected groups is below or near the threshold of extreme poverty. Then there is a great temptation to resort to more physical, brutal and public forms, in the name of his « social pedagogy », as enlightened despotism^[13].

It seems unnecessary to insist on the advisability of preventing or tackling this type of drift: political violence is unanimously considered as one of the main determinants of the human development deficit in sub-Saharan Africa, including the health component; and the state is by far the leading producer of political violence in the continent. However, this rejection of physical violence could not necessarily imply a disqualification of authoritarianism: numerous analysts, agencies and governments have « bet » at different times on more or less authoritarian regimes, usually in the name of stability. In fact, with respect to Covid19, various countries, and not just China, already seem to be legitimizing authoritarian management of the public good as being more effective, more guaranteeing of basic well-being, of health. Even in countries confidently auto-labelled believe they are democratic, polls published by the « fourth power », asking the population about who should make decisions, politicians or experts, are in danger of sponsoring a very undemocratic « government of the good », of infamous historical memories.

However, a rigorous analysis of the situation of the Covid19 (and of other comparable situations) tends to deny these commonplaces. Although in developed countries with broad levels of health coverage, state involvement in management seems to be one of the keys to a successful response, it is not equally clear that such success is proportional to authoritarianism and top-down centralism in decision-making. The evidence suggests rather the opposite: when the measures emerge from the involvement of actors and consensual coordination, the results could be better as a whole^[14]. This coordination is equivalent in decision making to the free flow of information inside the scientific community (paradoxically restricted by economic liberalism): against the demagogic image of a single scientific opinion (« truth »), the explanations of different specialists, and even more when coming from different disciplines, tend to have well-differentiated implications that must be continually balanced on the grounds of public good. There is nothing better than this incessant process of open and constructive criticism to modulate the social alert of Covid19 in Africa and avoid the hijacking of alarmism by the factions in the struggle for power.

Naturally, the disavowal of general confinement for the whole of Sub-Saharan Africa does not entail completely rejecting the concept. As some countries (Nigeria, Madagascar) are already doing (Nigeria, Madagascar…), partial closings or selective confinement can always be ordered (such as those for education or collective leisure, main transport nodes…) where their effectiveness can be assured, and once their convenience has been agreed. Moreover, components of the model could also be generally retained, such as the promotion of distancing provisions in daily treatment (in situations such as the essential local markets), or the adoption of sustainable hygiene practices, an initiative whose internalization goes beyond Covid19 framework.

In fact, structural support to the health system, with foreseeable effects beyond the current pandemic, should be a key criterion when choosing between different measures. Reflection on the disavowal of the second dominant model, that of mass detections, allows us to delve into this crucial aspect. Although the isolation of the patients is desirable in Africa as anywhere else, the great deficits of the healthcare system make it impossible to universalize the tests and the consequent medical control of positive people. Whether to confess or not, the same obstacles, the restrictions on access to the tests and the complexity of organizing « health missions » to go and find SARS-CoV2 instead of waiting for it, have prevented the adoption of this system, in principle the most promising, in many European countries. All in all, African NHSs could selectively approach the detection-isolation model. For example: targeting it primarily towards their healthcare professionals, who must also work under the best possible protection conditions, given the difficulty of replacing them. Probably the best way to guarantee these restricted actions is through international cooperation agreements between health institutions (hospitals, public health centres, health research groups), agreements that can be continued after the pandemic for the benefit of all parties. involved. This type of action would strengthen the health system and would have a great effect with limited investment.

In this same direction, a coordinated action of the African governments to obtain material for the hospital treatment of serious cases once isolated, as some analysts claim, could also be an advantageous measure in a market as wild as the sanitary is showing itself; however, it is an unlikely scenario. In fact, it is not lost on anyone that aid will be insufficient, probably diminished by the strain on the economies of the donor countries themselves (France, the United Kingdom or Germany, but also probably the BRICS, although China and perhaps India too may resurface earlier.) However, this does not mean that the national health systems are condemned to collapse, unless the authorities cause this wreck, prescribing and forcing the compulsory use of the facilities, something that once again appears unlikely.

Why not fear the catastrophic saturation of some healthcare services that are already clearly insufficient for their reference populations in « normal » contexts? In reality, the awe of the collapse of the small African healthcare systems largely projects European health expectations on sub-Saharan societies; and ignores or pretends to ignore that the 3rd SDG, « Ensuring a healthy life and promoting well-being for all and at all ages, » has not budgeted for its global health ambition. In many African countries, very limited health resources – facilities and personnel – remain underutilized. And it is not so much because of real barriers, as the frequent difficulties of physical access (distance and transport of potential patients) or imaginary or imagined ones, as alleged cultural –but usually non-existent- prejudices (that would suppose atavistic and not rational attachment to local remedies and therapies). The fundamental reasons lie in a calculation established by the users and potential users based on previous experiences, experiences that have caused people not to trust to be properly cared for, and this because of a whole host of reasons: the copayment, the limitations of patterns of selective primary care prevailing in the continent (of the GOBI-FFF type), the abandonment of public hospitals, the scandalous lack of qualified personnel in slums, provinces, and rural areas, or the routine of a “campaign medicine” with very restrictive goals (vaccines, maternal and child health aspects …). It is again unlikely that administrations will counterbalance this lack of confidence with measures more or less supported by international aid, which means that the NHSs will not be probably overwhelmed, at least not before substantially improving their healthcare offer.

This forecast, although negative in itself, has the virtue of further reducing possible international pressures to opt for confinement, since, without collapse, the disadvantages can far outweigh the advantages. Furthermore, it requires seeking solutions outside the apparatus of the national health system properly understood. And I am not referring to private medicine, unavailable to the vast majority, nor to international cooperation, particularly through NGDOs, which is already overflowing. Without forgetting them, and while recommending their articulation with public health, I think of community health.

After the Ebola crisis, some analysts, perhaps especially anthropologists due to their habit of looking closely, have been recommending the involvement of local communities and their accumulated knowledge, a recommendation that they renewed on the occasion of Covid19^[15]. This recommendation is probably better suited to the second dominant model and its adaptation to African contexts. If we start by focusing strategies on the protection of the most recognized risk group, the elderly, the key to this targeting would probably be to implement it in favor of its prestigious place in African society, and not as the allegedly more fragile, dependent and burdensome user-sector of the health system, as it is more or less openly conceptualized in developed societies. Achieving the participation of elders in crisis management could be a fundamental asset to mobilize the local population and their knowledge, given the socio-political influence of these people and their place in local collective decision-making, something that hundreds of studies have endorsed for decades, without prejudice to the modernization of African societies. Furthermore, one could limit consequences as distressing and relatively futile as those that followed the attempt of social medicalization during the 2014 Ebola crisis^[16]. In any case, it would seem wrong to consider this group as merely passive and vulnerable.

Mobilizing older people is still a community health initiative. Making it effective would require empowering local populations according to their own decision-making structures. This type of participatory measures could have health repercussions beyond the passage of Covid19, instead of generating temporary « deviations » or « exceptions » in reference to health local interests and resources, as happened with Ebola. In this sense, the stimulation of real participation, although it poses significant challenges, could contribute to three of the structural lines advocated for years for the sub-Saharan health field and almost totally neglected by international, multilateral or bilateral budget planning – a factor of an enormous weight in the sanitary supply in Africa. The first would be an operational enhancement of traditional and complementary medicines, in the sense promoted by the WHO^[17]: traditherapies provide agents, whose local recognition depends on their effectiveness; the exceptional nature of Covid19 could facilitate its interaction with the African NHSs in different ways, generating the necessary critical feedback, not only in direct relation to the SARS-CoV2. I just point that several countries, such as Senegal, Benin or Madagascar^[18], have declared that they are already conducting clinical trials on Covid19 with autochthonous herbal medicine.

Secondly, against the usual stereotypes and as African feminists have pointed out so many times, at least since the famous irruption of Ifi Amadiume’s work, local empowerment would facilitate the exercise of autonomy that women enjoy in many African societies. Consequently, this type of measures could contribute to making the role of the gender factor visible in this and other health episodes, stimulating the gender breakdown of information and the comparison of determining factors and effects, as well as prompting the activation of the diverse gender complementarities that can be found in Africa. Third, local health empowerment cannot be understood without articulating it with the corresponding public services. Any action in this regard would promote the much felt need for a greater territorial deployment of African health services, face-to-face and virtual; telemedicine could finally be more an opportunity for collaboration than a risk of disinvestment, an opportunity following a collective pattern quite different from Western hyperindividualization and optimizing public resources and African civil society. In this sense, the NHSs would inevitably be reinforced on the ground, but at the same time forced to combine the usual top-down actions with bottom-up initiatives and demands. This greater connection with the users could lead to taking seriously the2030 Agenda pending accounts, in the literal sense of the word, when we are still in time.

This text is not intended to end with the « letter to the Three Wise Men » of a cultural relativist. All indications suggest that the tracks I point to are more or less irreversibly underway, and with overwhelming diversity. Not in a planned way, but often as a consequence of the own deficiencies, inconsistencies and impotencies of African health regimes and of the policies promoted by governments with regard to the coronavirus, more to satisfy international pressure than after a contrasted assessment of the population interests and needs. It is everyone’s responsibility, but perhaps first of all for scholars and managers, to understand and value this diversity.

So far, Covid19 has not been too exemplary with respect to global health management, fragmented into national or corporate interests and lacking in effective coordination, not to speak about leadership, regardless of official speeches. WHO does not seem able to assume these roles due to lack of substantial and sustained financial and political support by the countries. But this does not exempt any of the actors involved from the need to model the consequences that it is having. The attempt to create an absolutely safe global health space, with eradication on the horizon, be it coronavirus or leprosy, is not only not realistic, but is inconsistent with its ultimate goal, the health of all, and now.

Its most repeated immediate effect, and foreseeably aggravated after the Covid19 experience, does not appear to be the increase in well-being, but rather the already known precariousness and rising cost of life. Particularly in Africa, the mimetic application of a global emergency could respond more to the will to generate – and sell – a feeling of security in Europe, North America or parts of Asia than to the needs, priorities and potentials of health south of Sahara. This trend, analyzed in other contexts by a multitude of researchers captivated by Foucault’s famous critique of biopower, has been undervalued by technocratic enthusiasts. However, even technocrats are looking at discourses coming from ecology, and that are consistent with this previous message. Covid19 is not going to vanish because viral infections are part of us, human beings, and not only of our sins, but also of our evolutionary potential. In fact, they are largely an adaptive product of our interactions with the global ecosystem, from the very fact of our lives, our economic activities^[19], so as « fighting » it would be in a sense « fighting » ourselves, at least part of our behavior. Without a doubt, neither China nor Europe nor the United States are exclusively responsible for these developments, but neither do they monopolize the hypothetic positive reactions for Humanity as a whole, the “solutions”.

It is difficult to question that African populations are socially and psychically (two of the dimensions of the famous WHO definition of health) more prepared for situations such as those posed by the pandemic. Reports and simulations of a possible pandemic in 2018, on the occasion of the centennial of the misnamed « Spanish flu », have hardly prepared global society for the SARS-CoV2 surge. However, many societies south of the Sahara have not only overcome catastrophic epidemic situations such as the Ebola outbreak, they not only live regularly with a level of spread of potentially lethal infections clearly higher than that of the current pandemic, but many of them they have also survived scenarios of social tension that are comparable to the current quarantines. I have no doubt that Malagasy society will survive confinement. Did it not endure a general strike of more than half a year at the end of the Second Republic, between 1991 and 1992, or, ten years later, a very hard mutual trade blockade between the provinces and the capital that, after months of pulse, would end with the flight of the until then President, Didier Ratsiraka? What about confinements in the South African townships or apartheid homelands? Or the forced reintegration of exiles in Rwanda, two years after the genocide? And I say this by citing only three of the countries that have already begun to apply the measures that the international community recommends regarding the coronavirus.

I do not doubt that they will survive, but I am also convinced -because the available evidence confirms this- that the optimal responses to the Covid19 challenge, the least painful and the least expensive, requires valuing this enormous baggage. Or, in other words, they go through a true alliance of knowledge between deeply different ones, an agreement that asks for the type of research that takes into account what is already known, but accepts that the future is yet to be built. It is time that we recognize that Humanity needs to learn from Africa. Perhaps in its distress Covid19 may help us in this sense*.