When COVID-19 struck, public health experts predicted that it would be particularly devastating in sub-Saharan Africa. A UN agency estimated that, in the worst case scenario, 3.3 million Africans would die from the disease. In a region that is poor, often with weak governments, and at best rudimentary health systems, the disease seemed to portend a disaster. In response, South Africa and Nigeria shut down their economies—as did most other African countries, to a greater or lesser extent. In general, African governments instituted the international public health recommendations of social distancing, handwashing, and mask wearing. The economic impact on the poor has been severe, but the lockdown measures seemed to work. Sub-Saharan Africa appeared to have a significantly smaller COVID-19 burden than other parts of the world. With much head scratching, observers cited the continent's relatively young population and the effectiveness of public health measures taken by governments.
However, in many, perhaps most, parts of Africa those public health measures were of limited duration—when they were followed at all. A large part of the population does not have ready access to hand-washing facilities, social distancing is impossible in the packed slums that most urban Africans live, and face-to-face interchange is central to traditional African economies. Face-covering seemed no more popular than elsewhere.
Perhaps South Africa provides insight as to the extent of the disease across the continent. South Africa has by far the most modern economy in Africa and has a strong government that implemented all of the recommended public health measures. The rate of compliance with them appears to have been high—in part due to heavy-handed enforcement of stringent protocols. Yet South Africa has nonetheless become ground zero for the disease: over 40 percent of sub-Saharan Africa's COVID-19 deaths are in the Rainbow Nation.
South Africa also has the best national statistics of any large African country. Deaths and their cause are compiled, registered, and published. Not so elsewhere on the continent. Ruth Maclean, writing in the New York Times, has looked at COVID-19 and African statistics. She finds that in most sub-Saharan countries, most deaths are never registered. Making reliable data on causes of death depends on anecdotal reports by grave diggers, funeral directors, and family members. In 2017, only 10 percent of deaths in Nigeria were registered. Khartoum has a rudimentary death registration system. But there, she cites a highly sophisticated study that credibly argues that COVID killed more than 16,000, rather than the 477 cited in official statistics.
A hypothesis is that COVID-19 deaths in sub-Saharan Africa are significantly underreported—even in South Africa. If so, the list of unknowns ranges from how many Africans contracted the disease, how many died, and how effective (or not) were the internally public health recommendations that governments tried to institute.