As Europe’s nations start to emerge from lockdown into spring sunshine, hoping infection peaks are behind them, epidemiologists are increasingly worried about poorer parts of the world.
While the worst of the early pandemic may be over or slowing down in China, Europe and the United States, the coronavirus is on the march elsewhere.
Developing and middle-income countries in Africa, Asia and Latin America which might have thought they had escaped the worst could instead be months off their peaks, health officials now fear.
The United Nations this week tripled the sum it says is needed to avert a Covid-19 catastrophe in the world’s poorest nations. It put out an appeal for a further $4.7bn for medical and food aid, on top of another $2bn requested in March.
A lack of reliable data in much of the world means case numbers and deaths are unclear and so far likely to be vastly underestimated. But the signs are alarming in several countries and the disease may continue to spread in developing countries for another three to six months, the UN said.
‘Rise in conflict hunger and poverty’
Meanwhile, the economic toll of lockdown is already leading to poverty and unemployment for millions.
“The most devastating and destabilising effects” of the pandemic “will be felt in the world’s poorest countries”, UN Under-Secretary-General for Humanitarian Affairs Mark Lowcock said. “Unless we take action now, we should be prepared for a significant rise in conflict, hunger and poverty. The spectre of multiple famines looms.”
Several leaders in the developing world have speculated that their countries may be spared the worst because of their relatively youthful populations. Younger citizens could result in a slower spread and a “slow burn” outbreak in some countries, epidemiologists have suggested.
But scientists also warn that any benefit from youth could be counterbalanced by poor healthcare and the unknown effects of Covid-19 on those who are malnourished and carry diseases such as malaria, tuberculosis or HIV. Parts of Africa are already causing concern.
Charlotte Watts, chief scientific adviser for the Department of International Development and a member of the Government’s Scientific Advisory Group for Emergencies (Sage), said: “It’s really hard to say where will be hit worst – it’s a disease that knows no borders and spreads quite easily around the world.
“But we are concerned now about the likely wave that’s going to spread across sub-Saharan Africa, and we’re starting to see numbers increase rapidly.”
Low testing in Africa
Africa has so far recorded 35,000 cases of coronavirus and over 1,500 deaths. This number is soaring every week, but experts say low testing means these figures only show a shadow of the crisis.
In Nigeria, Africa’s most populous nation, fears are mounting that the pandemic has spread far more than anyone anticipated. Over the last few weeks, there has been a spate of at least 640 mysterious deaths in the country’s populous northern Kano state.
Solid information on the situation in Kano is scarce. However, reports suggest that both doctors and gravediggers are being overwhelmed. Aminu Kano Teaching Hospital, a major hospital in Kano city, has reportedly been inundated with patients showing coronavirus symptoms.
In Tanzania, the situation looks equally grim. The country’s strongman leader, John Magufuli, is continuing to downplay the pandemic. His government has promoted church-going and steam inhalation as ways of combating the ‘satanic’ virus. As he refuses to put harsh measures in place, a stream of unconfirmed videos shows dead bodies lying on the street and men clad in protective equipment burying bodies under cover of darkness.
The figures on Africa’s medical preparedness are stark. On average sub-Saharan Africa has about one doctor for every 5,000 people, compared with 14 in the UK, according to the WHO. There are only an estimated 2,000 live-saving ventilators in the entire continent, compared with around 170,000 in the US. At least, 10 African countries have none at all.
Adam Kucharski, an epidemiologist at the London School of Hygiene and Tropical Medicine, predicts that the virus is spreading undetected in low and middle-income nations, with the impact to be seen in a month or two.
He told the Telegraph: “Our working theory is that although, for example in Africa, these are younger populations, I think because of comorbidities and other health conditions, you’d still expect potentially quite serious impact.”
Estimates of the human toll of that impact among African countries vary widely.
The World Health Organization said this week that 190,000 people in Africa could die of Covid-19 and 29 million to 44 million could get infected in the first year of the pandemic if containment measures fail. The body’s modelling sees the disease spreading more slowly than elsewhere, but “smouldering” for several years in transmission hotspots.
The United Nations Economic Commission for Africa (UNECA) has warned of an even more apocalyptic scenario: even with intense social distancing, the continent of 1.3 billion could see nearly 123 million cases this year. And some 300,000 people could die.
Deaths in rural India
India is also seeing a worrying rise in cases and it has long been suspected the official numbers are greatly underestimated.
Earlier this week, the Indian Minister of Health was still proclaiming that there has been no community transmission, even as the country that day recorded 195 deaths.
Despite spending 40 days in lockdown, cases are continuing to surge and show no signs of letting up – there has been a 14 per cent increase to 52,952 over the last 48 hours.
Again patchy data is likely to be clouding the real picture. Most deaths occur in rural areas, doctors say, and medical certificates stating the cause can be rare. Public health officials are left trying to check anecdotal indications of increased deaths.
In the city of Malegaon in Maharashtra, the state which has recorded India’s largest number of coronavirus infections, 580 deaths were recorded in April, double the figure for last year. Authorities are currently testing family members as they suspect the dead were coronavirus victims, unaccounted for due to the lack of testing.
India’s peak may still be two months away, said Dr Randeep Guleria, the Director of All India Institute of Medical Sciences.
Across India’s north western border, Pakistan has also seen deaths tick up ominously, even as ministers have tried to argue the disease is somehow less virulent in South Asia. Deaths have doubled to nearly 600 in 10 days and here too, the peak is not expected until possibly July.
In both countries the economic toll of the lockdown looks set to be
Pakistan could lose 18 million jobs and see a million small businesses go bust, Asad Umar, the planning minister said earlier this week. One in four Pakistanis have cut their food intake as a result of straitened circumstances and some 20 to 70 million may fall below the poverty lines as a result of the precautions.
Such an economic cost has forced both nations to relax their safety restrictions even as cases are still growing.
Indonesia is well on its way to becoming a new southeast Asian hotspot two months after the health minister, Terawan Agus Putranto, was citing an absence of cases as a “blessing from the Almighty”.
The death toll in the world’s fourth most populous nation currently stands at around 930, with many suspecting the figures are still unreported.
Mortuary workers have spoken of their exhaustion as they struggle to bury dozens of bodies piling up daily at cemeteries.
Cases doubling in Latin America every few days
And early hopes that the tropical climates of the Caribbean and Central and South America might act as some kind of defence against the coronavirus have also been dashed.
Brazil is now the epicentre of the disease in Latin America, with the number of cases at more than 100,000 and rising. Daily death tolls this week have been around 600.
Brazil’s far-right leader, Jair Bolsonaro, has consistently downplayed the severity of the virus, describing it as a flu or the sniffles. When he was asked about the day’s death toll of 474 at a press briefing last month, he replied “So what?”
Official death tolls again probably obscure the scale of what is happening. In the city of Manaus, just 532 deaths are attributed to Covid-19. Yet city data shows 2,435 people were buried in April alone, compared with 871 in April last year.
In Brazil, as well as Ecuador, Peru, Chile and Mexico, the number of cases is doubling every few days.
In the Caribbean, Haiti is at risk from a “perfect storm approaching”, said Dr Carissa Etienne, director of the Pan American Health Organization.
Although the country has reported only 100 cases, around 17,000 Haitians have returned from neighbouring Dominican Republic, where the disease is spreading widely, and this number is expected to reach 55,000 in the next few weeks.
Haiti’s health system is poor and the country has struggled to recover from a devastating earthquake which took place in 2010.
With months if not years of the epidemic left to run, the final distribution of cases could look very different by the end. Countries or regions of the world who at first thought they had escaped should be cautious, said Dr Josie Golding, epidemics lead at Wellcome.
“We have no idea how this will turn out and countries should prepare for the worst,” she said.