Almost a third of the more than 1,000 bodies transported to the Lusaka morgue in 2020 and 2021 tested positive for SARS-CoV-2, implying that many more people died of COVID-19 in the capital. Zambia than official figures suggest¹. Some scientists say the findings further undermine the “African paradox”, a narrative that the pandemic was less severe in Africa than in other parts of the world.

This idea arose after health experts noticed that sub-Saharan countries were reporting lower numbers of cases and fewer deaths from COVID-19 than expected. But researchers say Zambia’s findings may reflect a larger truth – that a testing deficit and strained medical infrastructure have masked the true toll of COVID-19 on the continent. The findings have not yet been peer reviewed.

Ignoring the true extent of COVID-19 in Lusaka and beyond “is so wrong. People were sick. Their families were destroyed,” says co-author Christopher Gill, a global health specialist at Boston University in Massachusetts. One of his colleagues in Zambia died of COVID-19 while working on the project.

“It’s not hypothetical to me,” Gill says.

Missing COVID cases

When SARS-CoV-2 began to spread globally, many health researchers feared the virus would devastate sub-Saharan Africa. But the surprisingly low number of COVID-19 cases reported in the region has led to the perception “that the severe impairments and deaths caused by COVID-19 were somehow less significant in Africa compared to other continents”, explains Yakubu Lawal, an endocrinologist at the Federal Medical Center Azare in Nigeria.

Lawal and other scientists have speculated² that the relative youth of Africa’s population might have helped spare the continent, but also suspected that the official figures were understated. The question was how much.

In search of answers, Gill and his colleagues in Zambia tested bodies in one of the largest mortuaries in Lusaka for SARS-CoV-2 for several months in 2020 and 2021. Test positivity was 32% in the whole – and reached about 90% during the peak of the waves caused by the Beta and Delta variants. Moreover, only 10% of people whose bodies contained the virus after death had tested positive during their lifetime. Some had been falsely tested negative, but most had never been tested at all.

Although Gill and his colleagues cannot confirm that all of these people died of COVID-19, the results still contrast sharply with official figures. So far, there have been fewer than 4,000 confirmed deaths from COVID-19 in Zambia, a country of about 19 million people. Separate findings released on March 10 suggest Zambia’s ‘excess’ deaths – those above what would generally be expected – from January 1, 2020 to the end of 2021 exceeded 80,000³.

Figures from Lusaka match statistics from South Africa, where a 2021 study found only 4-6% of SARS-CoV-2 infections in two communities were officially documented⁴. Further study of the same communities showed that 62% of study participants had been infected at least once from July 2020 to August 2021⁵. Co-author Cheryl Cohen, an epidemiologist at the University of the Witwatersrand in Johannesburg, South Africa, says many of these infections were asymptomatic, but people with symptoms may also have gone undetected due to cost. and difficulty getting tested.

Gill suspects that a key reason for the discrepancy between his results and official tallies is that most Zambians who die from COVID-19 do so outside of medical care. Four out of five people tested in the study were never admitted to hospital; the majority of unreported infections were among people living in poorer areas of Lusaka.

“No one is vaccinated. Nobody has masks. No one has access to the medical care they need,” says Gill. “We are in a population that is already stressed and in poor health, and then – boom! Comes COVID.

Great variation

But not everyone is convinced that the Lusaka findings invalidate the idea of ​​the African paradox. In Ethiopia, for example, “our experience is that people are infected with the virus, are asymptomatic or have mild symptoms, and recover,” says Amare Abera Tareke, a physiologist at Wollo University in Dessie. “While the current finding is hard to ignore, we should take it with caution.”

Gill fears that the idea that Africa has been spared the worst of the pandemic has led people to take unnecessary risks or contributed to the “lack of urgency” to get vaccines to African nations.

“I guess it might be unique to Lusaka,” he said, “But boy, you should really try to explain why.”