Transcript: Episode 30
What can we learn from Africa's response to the pandemic?
africa, people, ucl, ethnic minorities, levels, uk, impact, population, exposure, vaccines, factors, pandemic, communities, countries, research, support, structural inequalities, ibrahim, individuals, nigeria
Ijeoma Uchegbu, Ibrahim Abubakar, Vivienne Parry
Vivienne Parry 00:01
Hello and welcome to Coronavirus: The Whole Story, UCL's award winning podcast that documents research about the pandemic. My name is Vivienne Parry. I'm a writer, broadcaster, proud UCL alumna and your host to Coronavirus as examined, explained, researched and understood by folks in every corner of UCL. In this week's episode, we'll be taking you to UCL's description as the 'Global University' to heart, as I'll be talking to researchers from pharmaceutical science and global health, about the responses to Coronavirus in Africa, exploring why we haven't seen the levels of infection and deaths that were initially predicted. My first guest is Professor Ibrahim Abubakar, a Professor of Infectious Disease Epidemiology and the Director of the UCL Institute for Global Health. Ibrahim is the former head of TB at Public Health England and chaired the WHO strategic and technical advisory group on TB. He currently runs a global health research programme which addresses major diseases affecting vulnerable groups, and also sits on multiple experts in advisory groups, tackling diseases such as hepatitis and HIV for the who and the European Centre for disease prevention and control. I'm also joined by Professor Ijeoma Uchegbu, Professor of Pharmaceutical Nanoscience at the UCL School of Pharmacy, UCL’s Pro-Vice Provost for Africa and The Middle East, the Provosts’ Envoy for Race Equality, and Chief Scientific Officer and co-founder of the award-winning UCL spin out company Nanomerics Ltd. Ijeoma has won multiple awards for her own research, including the UK Department for Business Innovation Skills' Women of Outstanding Achievement in Science, Engineering and Technology award. So let's come to you, Ibrahim, tell me, first of all, what impact the pandemic has had across Africa.
Ibrahim Abubakar 02:00
Thank you very much. So I would start by reflecting on some of the doom and gloom stories at the very beginning of the pandemic, with most of the major headlines predicting the end of the world for Africa because largely of predictions of a weak health system. I think many of us are pleased and delighted that that has not turned out to be the case, estimates today suggests that in terms of confirmed cases, the African Centre for disease control put something like 2.1 million confirmed cases across Africa, most of them in South Africa and South Africa in particular, and just over 50,000 people have died. A large number, but given the size and population of Africa, a lot less than people have predicted. And this is despite all of the challenges to the health system. Now, I asked myself, are we asking the right question? And I wonder whether the right question or to be to turn this question on its head and say, why does the Western world have a higher level of COVID and a higher mortality rate? Why have things gone so wrong in Europe, the US, Brazil, etc. And maybe not so wrong in China, Korea, Kenya, New Zealand, or indeed the rest of Africa? And I think some insight through that analysis actually explains why things haven't gone so wrong in Africa.
Vivienne Parry 03:19
Can I just tackle a lot of people were anticipating that Coronavirus will be devastating across Africa. Why hasn't that been the case?
Ibrahim Abubakar 03:27
I'd be the first to acknowledge that there's a myriad of reasons why we are observing what we are observing. The first one is to acknowledge that the epidemiological number and data in terms of number of cases and it's in from Africa reported are probably are not under estimate, because of the absence of the molecular tests, the polymerase chain reaction type tests that are widely available here that may not be available in much of Africa. But despite the scale up of this testing, the level of positivity, which were initially high in some urban areas in Africa has not actually turned out to be and those levels have stabilised and in many African settings, including in Nigeria, in particular, we have done quite a bit of research, the levels have declined to comparable positivity levels to areas of the world such as in the UK. Well, we have widespread testing, as at well under 5% of individuals tested been positive.
Vivienne Parry 04:22
I absolutely let's go to the situation in the in the UK why that is, but some of the factors that might be contributing to lower incidence in Africa. So for example, exposure to in early life to lots more pathogens than perhaps here in this country. Things to do with sunshine and UV, young populations are all those things in the mix,
Ibrahim Abubakar 04:52
indeed to different degrees. And while none of those factors has been proven to be significant, I think their relative importance We are clearer than we were several months ago as to what is more important. So without a doubt, one would need to look at the factors in terms of the factors that drive transmission, and therefore the incidence of COVID. And the factors that increase the risk of death and mortality. And I would like to start with the mortality end of the spectrum, and to see that the younger age, the younger average age of the African population, and the fact that, for example, for many African states, the population of above the age of 6065, is of the order of 234 percent, compared to at least 20% in most European countries, and nearly 30% in Japan. But not just that, the levels of comorbidity in those age groups. So if you have diabetes in the UK, it's likely that you get access to health care, and therefore you could manage diabetes and live with it for much longer getting multiple preparations of insulin. If you're in rural Africa, the probability that you would have that and you would die from it is higher. So if you combine the smaller population, and the smaller levels of comorbidity, to a great extent, explains some of the differences observed between Africa and even other low and middle income countries such as Brazil and India. And I think that that's a big part of explanation. I think too much is made of other factors such as climate and levels of crowding, etc. But they also do have a role to play in this. I do think the idea that cross reactivity to other pathogens has a part to play. There's some data imagine from serological studies that show cross reactivity to exposure, previous exposure and stored samples to other coronaviruses in African populations that levels higher than stop samples. In the US at least one paper has been published showing that, but again, the contribution of that is yet unproven and more research is needed to get to know whether that is the case. Going back to the issue of mortality, there is an interesting paper that has been published in Nature, which suggests that there's a Neanderthal haplotype that increases susceptibility to severe disease. But I would argue that other drivers such as a comorbidity a explained and socio economic factors in the West driving increased mortality and comorbidity probably have a greater impact than just simply the genetic differences between different populations.
Vivienne Parry 07:18
So, I mean, this is such a fascinating area. Before we leave this completely the idea of using cross reactivity to other pathogens, but in much of Africa, for instance, allergies are relatively unknown compared to European populations, and you have a far greater exposure. So your immune systems pretty toughened up by early exposure. Do you think that plays a part?
Ibrahim Abubakar 07:46
So the so called hygiene hypothesis, as far as I'm aware, its role and implication in COVID has not been researched appropriately for one to see conclusively, but the data I was referring to is specifically that people are able to detect antibodies against the spike protein of other Corona viruses that affect humans, as well as in those same samples which are stored and prior to southgobi. They seem to react to the nucleocapsid protein around the Sasquatch to Coronavirus, which causes COVID-19 which suggests that if that is the case, it means people that have exposure to those Coronavirus is at a higher level than in the US. And this African samples, they may be better prepared to fight this exposure. I'm not convinced that there's any data or haven't seen any good data to back up the idea that it's in fact early life exposures that is causing any differences. Let
Vivienne Parry 08:42
me come to Iijima again to talk about Africa. Before we come back to people of African heritage in the UK it Gemma, how about the experience of the UK? I mean, most of the ways that different populations of the across the continent have been affected? And to what extent have social factors played a role in this in particular being from an ethnic minority within a country because we talked about ethnic minorities here, but of course, every country has its ethnic minorities.
Ijeoma Uchegbu 09:12
Yeah, one thing to bear in mind is sometimes in in some countries on the African continent, the medicine has been actually worse than the disease. And when I when I say that I actually refer to some of the lockdown measures that were imposed. For example, in Lagos in Nigeria, there were lots of very strict lockdown measures. And this was quite unfortunate because a large percentage of the population actually earned their money from working on a daily basis, ie if they do not go out to work that day. They do not actually earn any money to put food on the table in the evening of that day. So asking them not to go out and drive a taxi Not to go out and sell their wares in the market was was was really very detrimental to these populations because they could not comply, they simply could not comply with the rules and, and so imposing rules on populations, which inherently they could not comply with, obviously makes the nonsense of imposing those rules. And so you had popular governments on the African continent trying to to see whether the kinds of approaches that had been applied in the West could be applied on the African continent with very detrimental consequences. And I know that a lot of people living in das Bora actually had to provide care packages for their wider families in order to be able to make sure that people continued to be able to enjoy meals when they couldn't go out to work. So as as has been said, the impacts of the disease when you consider people actually dying from coronavirus and people actually being infected in a place where respiratory support is not really available. ICU beds are few and far between that impact was less compared to the west. But actually things like the lockdown the the measures that we are now unfortunately quite used to could not work in these areas. And and of course, yes, then you had consequences of that.
Vivienne Parry 11:27
They've been very effective lockdowns, I mean, Kenya was magnificent in its response,
Ijeoma Uchegbu 11:33
very effective lockdown, but you need to have some form of income support or some form of package to make sure that people who couldn't go out to work, were still able to feed their families and feed themselves. So some countries probably did that better than others. But I know that in Nigeria, in Lagos, the the support was really, really poor. The the level of support offered compared to the need, there was absolutely no match at all. And and so you had people then scrambling for the few care packages that were available from the States. And a lot of people then started preparing care packages of their own, because there isn't really a welfare state and a lot of African countries. And so the extended family is your welfare state by proxy. They started then, you know, preparing those care packages. So those kinds of poor thought through decisions, I think, had probably a bad impact as the coronavirus itself.
Vivienne Parry 12:33
So what you're saying is well controlled in terms of the health, but actually the impact, the financial impact has been devastating in some parts of Africa.
Ijeoma Uchegbu 12:44
Absolutely. And the world will I mean, we will all pay economically for the Coronavirus across the world. But I think that some communities in some countries will end up paying more than others and just return to that point about
Vivienne Parry 12:59
ethnic minorities within countries has there been a bigger impact on certain ethnic minorities in particular countries?
Ijeoma Uchegbu 13:08
So I'm not aware of any Nigeria, for example, is a good a good example. And a lot of the countries on the west coast of Africa consist of, you know, multiple tribes in Nigeria, there are three very large sort of ethnic groups and over 200 other languages are spoken by the more smaller ethnic groups. I'm not aware of those smaller ethnic groups been particularly impacted by the coronavirus either in the way of mortality rates, or in the way of, you know, economic deprivation. Of course, Nigeria is a country of two halves. The southern parts is more wealthier overall than this, especially the Southwest wealthier overall than the northern parts of the country. So it is probably an issue of economic deprivation being exacerbated by these unusual circumstances as opposed to ethnic minorities being particularly disenfranchised.
Vivienne Parry 14:08
So once more we're seeing COVID uncanny gift for spotlighting inequalities.
Ijeoma Uchegbu 14:15
Absolutely. And you know, we are going to talk about the UK but the UK is a case in point where you can actually see that levels of transmission and levels of mortality really do follow the socio economic distribution of people within the UK. It is so sharply illustrated. And there you actually see when we're talking about ethnic minorities, you can see the ethnic minorities within the UK are really at the sharp end when it comes to economic deprivation and their communities have suffered much more from Coronavirus deaths and the impacts of Coronavirus than, than other communities and you could you can really see that inequality. UK is one of the third most unequal countries in the world. After I think there's the US and I think it's Portugal that comes second, and the UK is about third and you can you can really see the impact of economic inequality and governments if it should that this should be a priority tackling economic inequality, because when such when a shock, like Coronavirus comes along, and certain people start dying more than others, it's not just painful, but it's also a huge loss to the country where in respect of talent, and human potential Abraham,
Vivienne Parry 15:37
let's go back to you again, because Jerome has already segwayed into this thing, which you raised at the beginning, that it's really we should consider this the other way around, not about Africa. But how people of African heritage have done in so badly in the UK. What are your thoughts?
Ibrahim Abubakar 15:55
So there are now very good data investigating this issue. And there are ongoing studies, including some that are being done at UCL led by my colleague, Rob Aldridge and what we are doing with the University of Leicester to fully understand the impact on ethnic minorities within the UK, the UK research study. And the data to date, including detailed analysis done by Public Health England, clearly point to structural inequalities and socio economic drivers as the root causes of the increased mobility and they act through two main ways. The first is those drivers of inequality increases directly the propensity for people to acquire covid, because they are in jobs that they are more likely to be exposed, whether it's as a bus driver, or as an NHS staff member, at the same time, levels of conditions that increase people's risk, such as diabetes, hypertension, etc. Again, higher driven by structural factors that mean that in communities that are predisposed to higher rates of this chronic conditions, they are inadequate public health interventions to lower the levels of this chronic diseases. So against a backdrop of higher levels of those conditions. It's not surprising if a condition such as COVID, that targets individuals who already have comorbidities and are older, that we have higher levels of deaths in ethnic minorities. But I will say very much that I believe the factors driving this are structural inequalities in society that just COVID is manifesting.
Vivienne Parry 17:25
And is it affecting black Africans in the UK, more than other ethnic minorities?
Ibrahim Abubakar 17:32
No, the data suggests that actually, it affects a wider range of ethnic minorities, not just like Africans, including ethnic minorities from the Indian subcontinent and Southeast Asia. Indeed, the genetic study I mentioned earlier, interestingly suggests the highest risk in terms of when when you isolate the genetic genetic risk factor is among people of Bengali descent, because that's the highest level. Interestingly, a Public Health England analysis, adjusting for multiple comorbidities backs up that claim out urge caution, however, that adjusting for multiple factors, when they're on the causal pathway is probably inappropriate, ie the presence of the greater exposure. And the presence of those comorbidities that are determined by disadvantage are probably the biggest drivers. And then the genetics kind of serves as an additional factor that exaggerate for those who happen to have those haplotypes.
Vivienne Parry 18:26
So more exposure, so bigger doses of bigger viral loads. And of course, we now know about COVID, that the more people you come across, the more likely you are to come across this disease, and so more likely to get it. But what about when people get into hospital, more likely to die too.
Ibrahim Abubakar 18:47
So the outcome of an infection such as COVID is primarily would be driven by how severe the illness that individuals are suffering from. And therefore if the individuals are a having to have a higher viral load or exposure, and therefore, and they are good hypothesis, suggesting that that's the case that you would get more severe disease if you get a higher viral load exposure. And then you have comorbidities at a higher level in those minority communities, whether it's diabetes or something else, then ultimately, this individuals would present a hospital with severe forms of disease. If they are lucky to also present later or to be admitted later, then that also was in circles. There is a lot of debate as to whether once people are admitted there is differential treatment by the NHS, depending on their ethnic origin. As far as I'm aware, there isn't good quality data to support that hypothesis. But if one looks globally, there are data that suggests for example, in the US black infants having differential care, depending on which physician they meet, whether it's a black doctor or a white doctor, which are interesting to show implicit unconscious bias in that health system. There isn't such evidence in our health system in the NHS, but I think until we research them properly, we don't know either way.
Vivienne Parry 20:00
Yeah, that was a shaming study was net. And it showed us as I recall that if the the obstetrician was a black woman then and the patient was a black woman, then the baby had something like a four times, four times increased chance of survival. I mean, really shocking. Iijima? Yeah, I
Ijeoma Uchegbu 20:18
think I'd like to pick up on that. And the study that was mentioned was indeed incredibly shaming showing that you know, that half is likely to die if that if you had a black physician looking after a black neonate. And also when the especially when the neonate had more complications, and less likely to die. But what I really wanted to say is that as well as and I think this is quite important, as well as really demonstrating as Abraham has said, the structural inequalities in our society and the socio economic inequalities. What Coronavirus has also demonstrated is that, even when you look at a narrow strata of individuals, all enjoying middle class professions and middle class lifestyles, you still found that physicians that were from black and Asian backgrounds did tend to start dying from Coronavirus, more than physicians that were from white backgrounds at the very beginning, if remember, when you saw the mortality rate with
Vivienne Parry 21:23
it was very marked, wasn't it
Ijeoma Uchegbu 21:25
very, very much. So what this tells you is that even in the workplace, the experience in the workplace of individuals who are now very well educated, enjoying a caring profession like no other and supposed to have a lot of respect, you know, this is a high status job. There was still key differentials that either expose them to more dangerous conditions with respect to coronavirus, lack of PP, etc, etc, we don't really know what and that research needs to be done. So not just earning less, but even when you're in a high status job, you do have a diminished experience compared to your peers. And that diminished experience can be viewed through the prism of race, and eventually is a is a is a matter of life and death. All of this
Vivienne Parry 22:16
has created an enormous sense of distrust and unhappiness in many ethnic minorities. Do you think this is going to translate to a lack of trust, for instance, about vaccines? Or do you think that that's put it the other way that ethnic minority groups should be first in the queue for vaccines?
Ijeoma Uchegbu 22:41
anecdotally, I do not feel I mean, you know, that people from ethnic minorities are less likely to adopt the vaccine, and they are less trusting of the NHS. I think, and and our health systems, I do not detect that. And unless there is real evidence showing that I don't think that we should, we should assume that the experience has been poor. But and and and it's been well known that, you know, there are there have been studies looking at pain relief and being given to women. And you can see that there's a difference associated with ethnicity. So there have been some studies done, but that hasn't translated into such a lack of trust that, for example, people don't go to their GP when they're unwell if they're from ethnic minority communities, or they're less likely to vaccinate their children. So I don't think that will be the case. I do think when you consider the vaccine, if we have a very finite resource, and it needs to be rationed, then it needs to go to those that are most likely to have a high impact or high negative impact from the disease. And so for me, I'm looking at the elderly in care homes. I'm looking at health health care workers that are on the front line. And I'm not particularly looking at different ethnic groups, but really looking at the the people that are more likely to either suffer high mortality or high morbidity from Coronavirus and that that being determined with objective criteria.
Vivienne Parry 24:11
Abraham, what are your thoughts on that?
Ibrahim Abubakar 24:13
So I would support the idea that ultimately what we want is to use these vaccines to achieve herd immunity. So really, it ought to be made available to as many as possible until we reach the population level protection that all of us are protected. I do think it's sensible at the very beginning to prioritise healthcare workers. And I think the government is doing so and to prioritise high risk communities with respect to whether or not there needs to be specific action in in ethnic minority communities. I think we need to stop or reflect on the fact that there has been a great deal of loss of trust globally across society, largely linked to the lack of transparency in information and I think that there's a lot of work to be done, to get people to trust that anything that is done by The system for them is actually for their own good and for the good of society. And to do that, we need to make sure that information is clear. The information provided is simple. And that communities are engaged really early on in the preparations, which a lot of which I know it's happening. So for example, in our work in the UK, a rich study, with health care workers, were engaged in all of the professional unions and associations of the different ethnic minority groups, and making sure that the work we're doing has got community buy in. And I think at the national level, collectively, we need to stop and think before we see evidence that there is any discrepancy that we are getting communities on site by providing clear information by being very transparent in the data, including sort of in the certification of vaccines. mhfa is an outstanding and superb organisation, and they should be given the free hand of free will to determine that these vaccines are safe. And once they do so we should all trust that they are safe and good for us and convince ethnic communities and the whole of society to take up this vaccines
Vivienne Parry 26:03
resounding words there and I fully support you. I want to just finish off by asking a more general question. What's the impact of COVID-19 in Africa taught us about pandemics generally, and how we respond to them.
Ibrahim Abubakar 26:21
It does tell us that responses have to be nuanced, and targeted appropriately to the key drivers of observed patterns, and that there isn't a generic response or anything on everything. I think it has exposed the fact that there are things that the African continent can do well, such as some of the very early responses, acknowledging some of the negative impact it has had both on the economy and in the care of chronic diseases, and making sure that the next time we have a pandemic, that countries are better prepared to provide the resilience and response needed. If aggressive measures such as lockdowns are undertaken, it is possible that in the future, the next outbreak would affect younger people. So the distribution of impact will be different. And Africa would not get away as lightly as it did this time around. And some of the infrastructure around HIV around Ebola and the lessons, as well as the lessons of COVID need to be brought together to make sure that we are prepared with the laboratory public health and other infrastructure and economic support to respond appropriately.
Vivienne Parry 27:25
Ijeoma Uchegbu 27:26
I think that one one thing this disease has taught us when we look at Africa, we look at Asia and we look at the UK is that we have to be humble enough to learn from people that have experience of pandemics and learn the way that they have coped with bad pandemics. Africa had Ebola and has has had a very serious HIV epidemic. And they have ways of coping, or countries on it in Africa and the African country have ways of coping with with these infections. We had never had anything as bad as this for the past hundred years. And we did show an unwillingness to learn from these other communities to learn from what happened with the first SARS and to learn what happened with with Ebola. So if anything, what this shows us is that we have to really be open to learn from others that know better than us and have had the experience before us.
Vivienne Parry 28:19
Well, I'm humble in the face of two magnificent guests this week. You've been listening to Coronavirus the whole story. This episode was presented by myself Vivienne Parry produced by UCL with support from the UCL Health of the Public and UCL Grand Challenges and edited by the magnificent Cerys Bradley. Our guests today to whom particular thanks, were Professors Ibrahim Abubakar and Professor Ijeoma Uchegbu. If you'd like to hear more of these podcasts from UCL Minds, subscribe wherever you download your podcasts, or visit ucl.ac.uk forward slash Coronavirus. This podcast is brought to you by UCL Minds, bringing together UCL knowledge, insights and expertise through events. Just talk content and activities open to everyone. Hope to be with you again soon. Bye for now.