Covid-19 and sub-Saharan Africa’s critical care infrastructure

The ICU capacity that is critical to managing covid-19 complications is severely limited in much of the region, warn Edgar Asiimwe and Saraswati Kache

The covid-19 pandemic has undoubtedly challenged our previously held assumptions about global disease epidemiology. Classic public health teaching promulgates the theory of a prevailing epidemiologic transition—one in which the burden of disease morphs from predominantly infectious causes to non-communicable causes as countries industrialize. That theory has now been turned on its head as public health campaigns in industrialized countries promote basic hygiene, while restrictive lockdowns upend regular life. For many, these developments feel like regression to a hitherto forgotten era, with industrialized nations now living the contemporary experience of many in developing countries.

But as industrialized nations grapple with this new reality, scrambling to treat the sudden rush of patients,
sub-Saharan Africa watches nervously from the sidelines—covid-19’s impact there would be catastrophic at best. It’s easy to see why: the
ICU capacity that is critical to managing covid-19 complications is severely limited in much of the region. In Uganda, for example, it’s been reported that there are only 55 functional ICU beds for a population of around 40 million people. Neighboring Rwanda has an estimated 50 for a population of 12 million, Tanzania has 38 for a population of 58 million, while South Sudan has 24 beds for a population of 12 million.

The significant burden of HIV among young people in the region, which is likely to leave them more vulnerable to complications, has also caused the World Health Organization to raise concerns about a potential difference in mortality demographics between the countries that have been worst hit so far and sub-Saharan Africa. As a result, an outbreak there could negatively impact Africa’s demographic dividend. 

Aware of these risks, many countries in the region have imposed aggressive containment interventions, closing schools and shutting borders. Yet despite these measures, there has been a slow, albeit unrelenting, uptick in confirmed cases, causing increased anxiety about an impending onslaught. Containment measures have also dealt massive collateral economic damage, further impoverishing many in central and west Africa, where over 80% of the rural population relies on seasonal and irregular work.

But why is sub-Saharan Africa’s critical care capacity so unprepared for this pandemic? At first glance, the reasons are similar to those seen in developed countries: critical care medicine is expensive. In much of
sub-Saharan Africa, as with other low and middle income countries, limited resources are an impediment to investment in critical care, a factor that often necessitates a utilitarian approach to healthcare spending. That approach invariably favors spending on the most prevalent infectious diseases, while neglecting other sectors in the health system.

The strategy has worked thus far: life expectancy has broadly improved in the region over the past two decades. But this specialization has left countries vulnerable to unpredictable health events, like covid-19, which can cause unfathomable loss of life and economic destruction. To illustrate, McKinsey now predicts that
sub-Saharan Africa’s economies could lose
between $37 billion and $79 billion this year alone; put in context, that latter projection is up to four times the amount spent on HIV/AIDs in sub-Saharan Africa in 2015.

This projected economic toll, in part, results from the swift and aggressive containment interventions many African countries have had to take in the midst of even single digit cases. In developed economies, the greater availability of ICU beds buffers against the need to introduce lockdowns at such a stage. Consider New Zealand whose gradually escalating containment strategy has had some success. That country has about 560 beds for a population of four million. Per the country’s modeling, population wide containment to prevent the overload of its health system was not necessary until reported daily cases were in the low hundreds.

The view of critical care as a deluxe aspect of health systems perhaps stems, in part, from observations in some developed countries that depict these wards as places where older patients with multiple comorbidities receive extremely expensive care in spite of poor prognoses. But the demographics of patients in sub-Saharan Africa’s ICUs often differ significantly from this trend. An audit from Uganda, for example, shows that patients in their ICU are often younger and without comorbidities. Moreover, some of the leading diagnoses requiring critical care, e.g. sepsis, and respiratory failure, are of infectious etiology. And yet mortality in this low income setting in sub-Saharan Africa was in excess of 40%. The resultant economic impact from lost QALYs and productivity of ICU patients in this cohort cannot be overstated. Robust critical care could help to mitigate this impact.

A reverberating aphorism during these times is that covid-19 is the “great equalizer”—one that has affected countries regardless of their wealth. It’s true this pandemic has taught us that infectious diseases are not just threats unique to low and middle income countries. In that same vein, it ought to be the same equalizer that teaches us robust critical care should not be an aspect of care singularly reserved for industrialized nations. The projected loss of life and unprecedented economic losses that sub-Saharan Africa faces should spur immediate consideration for strengthening its critical care capacity from governments and donors alike.

Edgar Asiimwe is a senior medical student at Stanford University School of Medicine. He holds a MSc in global health from Duke University and a BSc in biology from La Roche College. He is an incoming intern in UCLA’s internal medicine residency program and has a strong interest in global health and health system strengthening.

Competing interests: None declared. 

Saraswati Kache is a clinical professor in the Division of Critical Care, Department of Pediatrics at Stanford University Lucile Packard Children’s Hospital. She has a strong interest in critical care in developing countries and is a member of Stanford University’s Center for Global Health and Innovation.

Competing interests: None declared.