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# African malaria deaths set to dwarf covid-19 fatalities as pandemic hits control efforts, WHO warns

BMJ 2020; 371 (Published 02 December 2020) Cite this as: BMJ 2020;371:m4711

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1. Owen Dyer

Excess malaria deaths caused by pandemic driven shortfalls in prevention and treatment efforts will probably dwarf direct deaths from covid-19 in sub-Saharan Africa, the World Health Organization has warned.

Progress against malaria—dramatic in the first decade of this century—had already stalled since 2016 as foreign donors drifted away. But 2020 is likely to be the first year in decades to see an increase in deaths, WHO warned in its 2020 World Malaria Report.1

About 1.5 billion malaria cases and 7.6 million deaths have been averted since 2000, WHO estimates. But annual case numbers in sub-Saharan Africa have been unchanged since 2016 at about 230 million, and this year the region will fall far short of milestones set by the World Health Assembly in 2015.

“It’s likely that excess malaria mortality is larger than direct covid-19 mortality,” said Pedro Alonso, director of WHO’s malaria programme. Malaria killed 409 000 people in 2019 and 411 000 in 2018, most of them babies and toddlers in sub-Saharan Africa. A 10% disruption in access to antimalarial treatment could lead to 19 000 additional deaths there this year, WHO warned. More plausible disruptions of 25% or 50% in the region could result in an additional 46 000 or 100 000 deaths, respectively. The total number of covid-19 deaths recorded so far in sub-Saharan Africa is just under 30 000, of which more than two thirds occurred in South Africa.

Peter Sands, executive director of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, said at a meeting presenting the new WHO report, “The global health world, the media, and politics are all transfixed by covid-19 and yet we pay little attention to a disease that is still killing over 400 000 people every year, mainly children. This is a disease we know how to get rid of—so it is a choice that we don’t.”

Aid agencies fear that sub-Saharan African children, the people least likely to be killed by covid-19, will be those most harmed by it in the long term. Many African governments have imposed stringent restrictions during the pandemic. Unlike Arabic speaking north Africa, most sub-Saharan countries have seen far fewer than 1000 direct deaths. But the indirect damage the pandemic has wrought is likely to persist for years.

More than 50 million children lost free meals because of school closures, which in many cases have persisted for months and continue today. At least 250 million have been pushed out of school, and there is almost no online learning, a deficit that is likely to impact the region’s earning power for decades to come.

The pandemic caused the first economic recession in modern African history—usually the continent posts high growth rates—and most of the 50 million people it has driven into extreme poverty are aged under 18. While the average G20 citizen has had $1652 (£1238; €1371) in coronavirus relief, the average sub-Saharan African has received$38.

Africa’s relative youth and inaccessibility continues to protect it from the pandemic’s worst direct effects. “It’s clear the second wave is here on the continent,” said John Nkengasong, director of the Africa Centers for Disease Control and Prevention, last week. But, he added, “We’re not seeing hospitals being overwhelmed.”

Africa CDC hopes to begin vaccinations in the second quarter of 2021, said Nkengasong, although the cold storage requirements pose a special challenge. Vaccinating 60% of the population would cost about \$12bn, he estimated.

“Africa is neglected when drugs are available,” he said. “The worst thing for the continent is for covid-19 to become an endemic disease.”

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