Since the beginning of the COVID-19 pandemic, Africa has seen fewer overall cases and deaths than other parts of the world. Researchers have offered many explanations, from the continent’s younger demographics to its largely rural population.
But there may be a simpler reason: Not all the dead are being counted.
“To my mind, it’s not worth going any farther to explain this mirage of lower caseloads and death counts than the rest of the world,” Jonny Myers, professor emeritus at the School of Public Health and Family Medicine at the University of Cape Town, told ADF.
Myers has been outspoken about what he sees as a dramatic undercount of COVID-19 cases across Africa due largely to poor record keeping by government authorities.
For example, one study published last year found that only 10% of deaths were officially registered in Nigeria.
A different study in Khartoum, Sudan, used household surveys to determine that more than 16,000 people had died of COVID-19 there between April and September 2020 — a period when official records put the COVID-19 death count at less than 500.
“This is not a problem unique to Khartoum,” Oliver Watson, the lead author for the study by Imperial College London, told ADF. “In fact, we have seen lower rates of mortality detection in other urban areas during the first half of 2020.”
All African countries except South Sudan legally require deaths to be registered, but only eight enforce that requirement, according to a survey of 39 African countries by the United Nations Economic Commission for Africa (UNECA). Only four of those meet international standards.
Of the rest, a small group — Burkina Faso, Ghana, Liberia, Rwanda, Senegal, Sierra Leone and Togo — have begun using a technique called “rapid mortality surveillance” to capture all deaths in the country on a daily or weekly basis and compare that total to previous death estimates as a way to estimate COVID-19’s impact.
Tracking deaths helps countries shape public health measures that can address problems such as disease transmission. During the COVID-19 pandemic, death records have provided valuable data about the age and health of victims to help governments protect their citizens.
“Inadequate documentation and certification of death by natural causes (resulting from internal malfunctioning of the body) may delay timely public health interventions such as in situations where death arises from an evolving disease outbreak,” wrote Olusesan Ayodeji Makinde, the lead author of the 2020 study on Nigeria’s death reporting.
Yet, in the UNECA survey, 61% of those responding said their countries did not use death certificates to track communicable diseases.
As a result of poor record keeping, the UNECA reports, two-thirds of the deaths in Africa escape official registration systems. The are many reasons for the lack of reporting, including the cost of filing documents, the proximity of government offices to rural communities, and the use of digital versus paper records.
In place of reliable documentation, public health officials and government agencies use surveys, interviews known as verbal autopsies, interviews with grave diggers, and statistical tools to estimate death counts. Even then, UNECA classified 24 of the 39 countries surveyed as “very weak” or “weak” when it comes to capturing data such as cause of death in vital records.
The South Africa Medical Research Council, for example, recently reported that, as of early February, the country had experienced more than 135,000 deaths above normal since the start of the pandemic.
“This number is substantially higher than the 46,473 confirmed COVID-19 deaths reported by the Minister of Health to the same point,” the authors reported.
But even within South Africa, which ranks among the best countries on the continent for tracking vital statistics, death statistics vary widely by province. According to the Medical Research Council, the ratio of confirmed COVID-19 deaths to excess deaths ranged from 68% in heavily urban Western Cape province to 11% in rural Limpopo.
Excess death numbers track closely with confirmed COVID-19 deaths and positive COVID-19 tests, making it clear the excess deaths are directly related to the pandemic, the authors reported. They estimated up to 95% of excess deaths were related to the pandemic, which would nearly quadruple the official death toll if they were all properly registered.
Getting a true picture of the impact of COVID-19 on Africa would require every country to keep records at least as well as South Africa to see the difference between confirmed and excess deaths, Myers said.
“So, hypothetically, if excess deaths were available for other African countries, this would fill in some of the gap, but likely not all of the gap,” Myers said.