As we explained in part one of this blog series, there were already a number of weaknesses in a number of sub-Saharan African countries’ health infrastructures, which were just exacerbated by the COVID-19 pandemic. While tools for treating and preventing the virus and severe cases have gotten better, there are a lot of places that still struggle getting these resources to all the people that need them, especially given worldwide challenges with shipping and availability in general.
Our Director of Africa Partnerships Nadia made the point that COVID-19 shows that anyone can be affected by disease if it’s prevalent enough in a community, “COVID-19 has been a powerful equalizer: affecting all of us irrespective of our geographic location or socio-economic status.” While it has uprooted a lot of the things we considered normal, it has also given us the rare opportunity to personally empathize with people in parts of the world that have not had access to good health care, clean water, and proper sanitation facilities for years.
COVID-19 in Africa
Africa has seen its longest decline in COVID-19 infections since the start of the pandemic, peaking at over 308,000 weekly cases at the start of 2022, compared to about 20,000 a week now. Currently no country is witnessing a resurgence, but experts maintain the importance of staying vigilant in surveilling the virus, detecting variants, and vaccinations, especially since the risk of new, potentially more deadly variants remains. As most countries in Africa are in the southern hemisphere (yet easing restrictions), there also runs the risk of colder weather causing another surge, potentially of one of the new sub-lineages of the Omicron variant.
According to Africa CDC and AU, as of April 30, the continent of Africa has had 11,446,107 COVID-19 cases, 2% of all cases worldwide. In terms of the WHO African Region, Ethiopia has had the second largest number of cases (470,273). There have been 252,157 deaths, with South Africa leading at 59%, followed by Ethiopia (7,509). There have also been 10.8 million recoveries, for a recovery rate of 93%. Despite an increasing number of vaccine supplies going to Africa, just 16% of the continent’s population is fully vaccinated. See the Africa CDC’s vaccination dashboard for updates.
The Africa CDC releases a weekly outbreak brief, biweekly briefs on the latest developments in science and public health policy around the world, and updates on the latest guidance for African nations. You can also see the WHO African Region’s COVID page and dashboard.
Lower Than Expected
One interesting aspect of the pandemic in sub-Saharan Africa is that its effects have not been nearly as devastating as public health experts were predicting at the beginning of 2020. There are a lot of disagreements about whether this is accurate, and if so, why that is.
While South Africa did have huge waves with the Delta and Omicron waves comparable to what we’ve seen in the US, these numbers weren’t reported in most countries in sub-Saharan Africa. Blood samples indicate that antibodies for the virus are much higher than expected, especially given the low levels of vaccinations, which suggests a lot more people than previously thought have been infected. Even in South Africa where testing and recording of deaths is comprehensive, there were 250,000 more deaths recorded for natural causes than expected, suggesting that COVID could have caused even more of those.
Whether there have been less infections or less symptoms among the infected, many think this could be due to how many young people are in the region, nearly two-thirds of whom are younger than 25, and less likely to have comorbidities that cause complications to the virus. Other hypotheses are that people are more spread out than in other parts of the world, less mobile, and more of their lives are spent outdoors. Or maybe other pathogens have somehow helped people respond to the coronavirus. The problem with some of these theories though is that while India also has a lot of these same circumstances, their COVID deaths have been in the millions.
Another important differentiation is that a lot of people prefer to bring their loved ones home from the hospital when they are about to die or don’t make it to a medical facility at all, meaning a lot of deaths aren’t recorded with civil authorities. One research team in Zambia found that 87% of the bodies in the morgue were infected with COVID. Other people disagree that there could have been so many more deaths from COVID than expected since so many places have bigger traditions for burials, and they haven’t reported an abnormal number of funerals.
Looking at vaccination campaigns, focusing on people who are immunocompromised such as those with HIV/AIDS, home tests, drugs to treat COVID, and monitoring variants is essential going forward in Africa. Either way, the world will need to work together to make sure that our brothers and sisters in Africa are not left behind as we all start to get used to living regular lives with COVID.
COVID-19’s Impact On Progress
Our Executive Director remarked early on that our partners have been fighting another viral epidemic for many, many years, with far fewer resources, yet they “remain hopeful! They persevere.” We can learn from them how to have hope in trying times, appreciate moments with ones we love, and see the power of a community working together for the greater good. And since we believe everyone has a right to proper sanitation and hygiene, we will continue to fight for that to become reality.
Blood:Water partners have been stepping up for some time to address communities’ need for soap, a small thing that gives life. “Clean water is a fantastic part of keeping people safe and healthy. Clean water with the necessary hygiene practices and tools is even more fantastic. Our partners provide both.”
COVID-19 and WASH
COVID-19 had huge effects on the global economy, adding between 119 and 124 million people into extreme poverty in 2020 for a total of about 1.8 billion, or 23% of the world’s population. They often have much lower access to WASH (water, sanitation, and hygiene), and at the current rate, while basic hygiene services improved to 48% of people in fragile contexts from 43% in 2015, only 58% will have them by 2030.
Measures to address the pandemic often meant disruptions in efforts to spread WASH, which we won’t know the full effect of for a while since it was harder to gather data. There was a more global focus on handwashing as a part of infection control, including emergency support to utilities and vulnerable households. A survey of more than 3,000 randomly selected individuals in six African countries found that COVID caused a significant disruption to WASH services, and around one quarter of respondents found it more difficult to access drinking water, skewing towards rural populations.
In 2020, four out of every ten people in rural areas and 2.3 billion people lacked basic hygiene services, and in sub-Saharan Africa, two out of five had no hand-washing facility at all, which increased to 35.4 million people due to population growth. Only one in four people in fragile contexts in the region used basic hygiene services, compared with one in three in non-fragile contexts. Access varies widely within regions and countries, but coverage in urban areas was generally higher, though rates of progress were higher in rural areas.
COVID AND HIV
Our co-founder Jena Lee Nardella wrote, “Coronavirus is our newest global pandemic, and the world has things to learn from those who have spent the last 30+ years addressing the global pandemic of HIV – quite different from coronavirus, but requiring local, national, and global responses nonetheless.”
Coronavirus impacted the fight against HIV/AIDS in a myriad of ways. Scarcity and increased costs of food and resources for proper nutritional health made it difficult for immunocompromised people and for those in poverty to get food needed to stay strong. Many HIV support groups were not allowed to meet, an integral and vital part of combating negative effects of social stigma, and a lot of people living with HIV ended up skipping medical appointments because they were afraid of having to quarantine (missing work on a day-to-day income) or of contracting COVID there, including pregnant women who need their medications to ensure their babies are born HIV-negative.
Nadia also attended a global AIDS conference where she learned that HIV and COVID-19 had an even greater overlap than previously expected. The history of treatments and technologies to respond to HIV provided a LOT of helpful insight into how to handle the coronavirus, hailed by health experts as the single most relevant experience to COVID response, including the community-centered approach of both.
People living with HIV are more likely to become severely ill with Covid-19 and die if hospitalized, according to a large new study. Sub-Saharan Africa makes up about two-thirds of HIV cases worldwide, and about 95% of the 268,412 people hospitalized with COVID-19 in the study. Many patients had other conditions such as high blood pressure, diabetes, and obesity, and more than one-third of the patients with HIV were severely ill at their time of admission. Nearly 25% of all these people died, the risk being highest for people older than 65 and older men.
After adjusting for other conditions, it is estimated that HIV increases someone’s odds of dying from Covid-19 by 30%, contradicting findings from several smaller studies. Experts say this study is more biologically plausible, given HIV’s ability to disrupt immune defenses, and since HIV can cause a lot of comorbidities, adjusting calculations for them may skew these findings lower than they may actually be. On the other hand, doctors are more likely to admit Covid-19 patients with HIV to the hospital, out of an abundance of caution, skewing results as well.
South Africa’s primary two strategies toward addressing new variants of COVID-19 revolve around testing and HIV treatment. 8 million people there (13% of its population) are living with HIV, and when they adhere to their treatment, they can achieve viral suppression. Without it, the virus can replicate unhindered and attack their immune system.
Of the 25 million people with HIV in sub-Saharan Africa, 17 million have achieved viral suppression by adhering to their treatment plan. It can take weeks or months for their bodies to be able to fight off the coronavirus. When it’s present that long without much of a fight from their immune systems, it has time to mutate to create a (or multiple) new version of the virus that can be passed on. Researchers have found at least two cases of this: one of a 36-year-old woman who had coronavirus for 216 days that created 32 mutations.
Even more troubling is that one of these mutations could eventually evade vaccines. People with HIV aren’t the only ones whose systems give the virus a chance to mutate; it can happen in anyone immunocompromised like transplant and cancer patients or people with typical immune systems, who normally can fight off the virus in a couple weeks.
The other half of South Africa’s response strategy, the KRISP lab, sequences thousands of coronavirus samples every week, part of a national network of virus researchers that were the first to identify the Beta and Omicron variants. Previous experience fighting HIV has also helped them become global leaders in studying how the virus changes, its relationship with other viruses, hotspots of transmission, and contact tracing that help prevent further spread. They sequence samples from across Africa, something absolutely essential to keep a grasp of the virus on the continent, where other resources like data collection and treatments are less widespread.
HOPE FOR A VACCINE
The Vaccine Research Center opened in 2000 at the National Institute of Health, and although about 85 HIV shots have been tested, none have worked. Vaccines work by giving the immune system a small taste of an invading microbe to prepare it against the real virus. Among the reasons HIV has been impossible to vaccinate against is that while other viruses use some protective mechanism to evade the immune system, HIV seemed to use all of them. Dr. Barney Graham said: “If we could figure out how to make an HIV vaccine, all the problems with other viruses would be solved.”
Some researchers at the center tried to map the detailed structure of HIV’s spike, the protruding protein that allows the virus to invade cells, then identify the part of the spike most vulnerable to antibodies (the part of the immune system that recognizes viruses and blocks spikes from other cells). While the goal was to make a vaccine that could show the immune system the problematic section of the spike, HIV spikes constantly change shape before and after invading a cell. Ideally they could identify the initial shape to have the best chance of preventing invasion, but scientists struggled for years figuring out which shape to choose, comparable to “trying to grab Jell-O.”
In 1960 scientists learned that what got DNA (which held the blueprints for making proteins) to ribosomes (which did the work producing the proteins) was messenger RNA, or mRNA, though it was nearly impossible to isolate because it fell apart as it was removed. Dr. Katalin Karikó and Dr. Drew Weissman saw that mRNA could allow a vaccine to carry instructions for cells to pump out viral proteins, which would cause a stronger immune response than traditional vaccines, and eventually discovered how to change mRNA in the lab before injecting it into cells. A team led by Pieter Cullis spent years working on a “package” that could move genetic material into cells, though they shifted focus to licensing technology to a new company, led by Ian MacLachlan, whose team in 2004 encased genetic material inside fatty coats that kept lipids from escaping or breaking up genetic material as soon as it arrived at cells. All of these combined to give scientists the ability to transport RNA safely in the body in the form of a vaccine.
Dr. Jason McLellan got to know Dr. Graham at the Vaccine Research Center, and as he prepared to open his own lab at Dartmouth, Dr. Graham suggested it should focus on coronaviruses. These were similar to HIV in that their spikes moved around, preventing a vaccine or reproducing and isolating it in a lab. In a few years, the team published intricate images of the spike, helping Dr. McLellan and Dr. Nianshuang Wang zero in on a loose joint of spike on MERS and make the whole protein more rigid to map it. When Chinese researchers posted COVID-19’s genetic sequence online, Dr. McLellan’s team used what they had learned before to come up with genetic sequences in days.
On February 15, 2020 Drs. Graham and McLellan published a paper detailing the spike’s structure. The COVID vaccines that resulted from these peoples’ and many others’ work could result in other new shots against diseases from the common cold, to the flu and cancer — even against HIV! Manufacturers say mRNA will allow them to adapt vaccines quickly, to fend off whatever variants pop up next.
Community-led organizations run by and for people living with and affected by HIV rallied to meet challenges in a remarkable way to protect people in their communities, and investing in them will enable us to be much better prepared to respond to challenges coming. In a UNAIDS survey, 225 community-led organizations from 72 countries responded on the impact COVID-19 had on HIV-related work, and their contributions to COVID-19 response. They moved swiftly at the onset of the pandemic to mitigate its impact on communities, undertaking a wide range of new activities to ensure continuity of HIV-related services and bolster health and well-being.
Most organizations had to stop at least some regular services because of lockdowns, travel restrictions, out-of-stock medicines and PPE, and concern about the spread of COVID-19. They struggled meeting multiple new challenges at the same time that affected delivery and access to services and basic necessities like food, antiretroviral (ARV) medicine, and self-testing kits, stretching resources as far as they could. They moved services online and spread awareness through websites, social media, (particularly in sub-Saharan Africa) radio, individual communication, and support groups, though many were concerned about the quality of interactions. They distributed masks, soap, and sanitizers, and constructed handwashing facilities, though many had to find innovative ways to produce these themselves.
Many emphasized the importance of the deep connections they’ve created with communities, raising awareness, and improving communication between communities and governments. They’ve developed substantial knowledge and capacities over decades of work combating HIV, so that they’ve become “pandemic experts”.
Our Partners’ Responses
756,761 Individuals Trained on COVID-19 Prevention
1,898 Community Hygiene Facilities Established for COVID-19 Prevention
11,710 Households Reached with COVID-19 Hygiene Interventions
39,683 Individuals Provided with COVID-19 Hygiene Interventions
16,211 Individuals Provided with Facemasks for COVID-19 Prevention
6,138 Individuals Provided with COVID-19-Related Livelihood Strengthening
Blood:Water partners with African-led organizations serving their local communities, and our partners’ ongoing health work is directly related to the COVID-19 crisis. As our world has battled this new virus, our partners remain on the frontlines, leading their community response. While the world focused on the formal health sector’s capacity to deal with COVID-19, a lot of middle and low-income contexts depend on community health structures as a lifeline for essential health services and life-saving information for people who could not otherwise not have access to them. This is certainly the case in Africa, where our grant partners worked hard to shift ongoing WASH and HIV programmatic efforts toward emergency COVID-19 responses.
Our partners have been hard at work, ensuring adaptability and preparedness among their teams and communities. Many have emerged as leaders at the national level in their countries’ response to the pandemic. Before the first cases of the coronavirus emerged on the African continent, our partners were already pivoting their services and mobilizing teams to educate communities on the virus and how to prevent it. We are standing right beside them, equipping and empowering them through financial resources, organizational strengthening (OS), and systems support.
Each partner adapted services and outreach based on government restrictions and guidelines, and what they learned from other countries. We allowed partners to allocate program funding to help meet the basic needs of families dealing with economic difficulties through things like food and nutritional support, assistance with school fees, medical fees, and more. We encouraged partners to rethink service delivery models to continue essential aspects of their work while adhering to movement guidelines to prevent the spread of illness.
In the wake of COVID-19, Blood:Water pivoted the focus of technical services to best support our partners in their COVID response to their communities. A few of our partners took part in the virtual training program GlobalGiving Accelerator. After the training, organizations entered into a campaign, where they raised a minimum of $5,000 from at least 40 donors. Once this is achieved an organization graduates and secures a permanent fundraising spot on the GlobalGiving platform.
Blood:Water was among a handful of organizations championing the centrality of communities to effectively prepare for and combat COVID-19 in Africa, African leadership, resource community organizations, and community systems strengthening. As part of this, we developed the COVID-19 Community Response Monitoring Tool and a supporting Guidance document for COVID-19 prevention, community disease surveillance, and emergency relief efforts in four countries. It anticipates a range of community-based COVID-19 response efforts needed to scale immediate, widespread prevention and preparedness, and tracks relief efforts needed to safeguard household livelihoods with basic needs that can compound the health crisis. We shared it widely for any community health service provider, funding partner, or agency that supports community health and plans to join forces in the global fight against COVID-19.
For more about this tool stay tuned for part 3 of this blog.
We were seeing positive trends in OS initiatives prior to the pandemic, but some of these activities revolved around group gatherings and physical proximity of staff. To foster connectivity in the face of forced isolation, we instituted weekly calls with our partners that enabled them to connect with each other and with Blood:Water, share resources and insight, and support and encourage one another. We saw a lot of great responses to virtual OS events, such as webinars, and since these are so cost-effective, accessible, and can be archived for future reference, we expect to accomplish a lot more in this realm.
To diversify the technical services available, we also started individual leadership coaching, so leaders could work 1-on-1 with a trained and certified coaching professional to identify and work towards professional, organizational, or personal goals. Over the course of ten coaching sessions based on the schedule and agenda set by the leader, they work on goals to move teams and visions forward powerfully.
In 2021, our AP team launched the Leader Collective to be a public good that amplifies and leverages our impact to better serve partners in the ongoing COVID-19 constrained context. Born out of our missional mandate to invest in partners and their visions for lasting change, it is a virtual community that exists to convene, cultivate, and amplify African leadership, driving change in health and development sectors. In the coming years, we look forward to continuing to build out the online platform of the Leader Collective and expanding its membership offerings to aligned, African, community-focused organizations.
INITIAL REACTIONS TO COVID
When COVID began reaching eastern Africa, several partners quickly had most staff working from home, and tried to reassure everyone despite their anxieties. Every country had different restrictions to curb the spread of the virus, which all of our partners quickly adapted to to continue keeping people healthy. Community members often had a hard time accepting distancing measures, since they contradicted cultural greetings, and most countries had periods where they could no longer gather in groups, impacting how partners were able to share important information.
LWALA gave community health workers (CHWs) with underlying conditions or anxiety about their risk the option of opting out of service, yet all 300 stayed on to help the 90,000 people they serve, each taking on 50-100 households. They kept smartphones on their person so they could ask face-to-face questions if need be in the field.
Some partners provided testing to have a better understanding of their communities’ situation, and put those who tested positive on home isolation with full doses of medication. They also distributed reusable masks, soap, hand sanitizers, and gloves to community members, health workers, and vulnerable households, such as families with at least one person living with HIV. They followed government guidelines, spreading information about the virus far and wide through community drives, call-in radio programs, spot messages, educational materials, small groups, and one-on-one meetings on preventative measures, especially to high-risk individuals.
LWALA’s Managing Director, Julius Mbeya, was stationed in Kenya’s capital to participate in the National Response Committee’s community outreach to share accurate, essential information, and participated in a memo presentation to the senate on suggested guidelines. LWALA also worked closely with the Ministry of Health to create national guidelines for the country including a training guide for CHWs and community health guidelines to respond to challenges delivering household services for workers going into the field.
OLPS made contacts with household members so they could check in and ensure they were following prevention guidelines, helping counteract the social impact of COVID-19 with things like school fees and cash subsidies for businesses. They also worked with the Kenyan Ministry of Health to train health staff, community health volunteers, and case workers on COVID-19, and helped caregivers start an income generating activity of their choice and join a local savings group.
Several partners focused on nutrition, providing households, orphaned and vulnerable children (OVCs), and early childhood development (ECD) centers with food and nutrition education sessions on things like infant and child feeding, food management, food safety, food processing, food recipes, and food production. They gave out seeds for people to plant, helped them produce low-cost crops to improve dietary intake and meet minimum requirements for a healthy diversified diet, and did cooking club demonstrations and door-to-door education and counseling on eating well.
MAINTAINING ESSENTIAL PROGRAMS
Our partners knew they had to place WASH at the center of their efforts, and make sure every household had access to a handwashing station, soap, and water. They purchased and distributed soap to families, health facilities, and schools, especially for those most at risk, such as people living with HIV and the elderly. They found new schools, houses, communities, public facilities, local markets, and community centers for new and rehabilitated water points and handwashing facilities, and registered households and WASH committees to spread information on sanitation and hygiene practices, and operation and maintenance of water facilities.
They held trainings, outreaches, door-to-door walks, and Q&As on WASH, HIV/AIDS, and COVID-19 so that communities could maintain their health. When they couldn’t do these, they facilitated household checks to ensure existing facilities were being properly maintained, outfitting them with PPE and COVID-precaution training.
For people who couldn’t go to health facilities to retrieve their ART (antiretroviral therapy) medications due to social distancing protocols, or fear of contracting coronavirus or being quarantined, our partners tried to ensure all HIV-positive clients had three to six months of supplies. They continued regular programming such as counseling and testing for HIV, and served new OVCs through home-based visits and children’s clubs, providing self-test kits when necessary.
All of our partners had a hard time using their organizational strengthening funding to do what they originally intended to do. LWALA eventually conducted a leadership workshop to counteract zoom fatigue and isolation which gave them the opportunity to regroup old and new leaders, build trust through fellowship and conversation, renew commitment to the organization, and inspire staff to innovate and take initiative. COPRED purchased a vehicle to safely reach beneficiaries during and beyond the COVID-19 response without needing to rely on an external transport service.
We honored all of our partners leaders with our annual Leader of the Year award in 2020 because of their astounding work in the face of COVID-19. Julius’s fearlessness and expertise allowed LWALA to become a frontrunner in the push for the Ministry of Health to support a home-based care model for clients who no longer could go to the hospital as a result of restrictions. Geoffrey’s steadiness allowed PaCT to keep looking forward despite the unprecedented nature of COVID-19, and to become a key actor in the Ugandan Ministry of Health’s response. Jimmy advocates for communities he serves, holding those in power accountable to do the same with the utmost seriousness, ensuring no community is overlooked. Hermella is a fearless optimist who brings a lightness and joy to Drop of Water, helping her team flexibly respond to changing dynamics until they see “100% access to clean drinking water, adequate sanitation, and hygiene in all parts of Ethiopia.”
We say this a lot, but we truly couldn’t do any of our work without these amazing heroes and the way they selflessly go out into their communities every day to stand up for everyone’s human right to health.
How a Latrine Gives an Education to Girls
Best friends and 14-year-old primary six students in Kiggwa, Uganda, Isabella and Griffin, were happy to find out that school was canceled due to the COVID-19 lockdowns. There were many times they didn’t show up anyway because of the shame girls received from other pupils while on their periods since there was no changing room for them to use.
When the country finally announced that schools would reopen Isabella and Griffin were both afraid to return, but more afraid of telling their parents they didn’t want to go back. After they skipped the first day under the pretense of needing to pick up school supplies, a friend of theirs told them there was a new girl-friendly latrine in their school, constructed by a local organization. When they went back to school to see it for themselves, the head teacher even explained that the new, clean latrine had an extra room just for girls.
Isabella recounts this herself, saying, “I think it’s written all over our faces with the big smile I am putting on with my best friend, and this is because of the big relief we have with the girl-friendly latrine constructed in our school… We are so happy and thankful to PaCT for solving our problem. We can’t wait for the school’s health club because we both want to be a part of the club so we can help our fellow pupils who are in the same situation. God bless PaCT and the hands who have shared their blessing with us, the pupils of Kiggwa Primary School.”