"The WHO is," says Oyewale Tomori, "well, I know the W stands for World, but sometimes I think it stands for White."
Tomori is a virologist at Redeemer's University and the past president of the Nigerian Academy of Sciences. I had asked whether he was surprised that high-income countries were buying up monkeypox vaccine supplies and WHO was sharing its vaccines with 30 non-African countries, leaving the continent without access.
"Are you surprised when the sun rises every morning?" Tomori retorts.
He tries not to get too upset about global health inequities because he thinks they're inevitable. The real issue, he says, is that African countries rely too much on the West — which is not exactly a formula for success. For one, Tomori says, Western aid always comes too little, too late. But more important, he stresses, "your help is not helping us. It's making us more dependent."
Fed up with their countries' inadequate responses to Ebola, COVID-19 and now monkeypox, a growing movement of African scientists is advocating for improved biosecurity on the continent – that is, protection against pathogens.
To better understand their grassroots effort, I spoke with Tomori; Jean-Vivien Mombouli, director of research and production at the Congolese National Public Health Laboratory; and Christian Happi, director of the African Centre of Excellence for Genomics of Infectious Diseases in Nigeria. I wanted to learn, more specifically, what they think Africa should be doing to contain infectious diseases. They offered three key ideas: developing community-based disease surveillance; building capacity to produce protective gear, vaccines, and other pandemic-busting tools; and investing more in health-care workers.
The elephant in the room is whether achieving all this is even possible since African public health systems have long been underfunded. As one example, African Union member states pledged to spend 15% of their national budgets on health in the 2001 Abuja Declaration. Two decades later, that's happened in only five countries: Ethiopia, Gambia, Malawi, Rwanda and South Africa.
Nonetheless, Tomori rejects the notion that Western philanthropy is the answer. "Don't buy the story that Africa is poor," he says. "We're not poor; it is that we're not making good use of what we have."
But change is possible. And in fact, it's already begun.
Teach communities to keep an eye out
One of the primary steps toward biosecurity is comprehensive disease surveillance to help rapidly identify and contain novel pathogens — this includes the health-care system treating patients, public health labs conducting tests and epidemiologists coordinating the response. While the World Bank has invested hundreds of millions of dollars in Africa for this purpose, Mombouli says the continent still doesn't have sufficient surveillance in its more rural regions, enabling viruses to spread undetected throughout.
Perhaps the most infamous example was during the West African Ebola epidemic when it took nearly three months to identify the virus in Guinea. WHO reported that the country took so long because "Clinicians had never managed cases. No laboratory had ever diagnosed a patient specimen. No government had ever witnessed the social and economic upheaval that can accompany an outbreak of this disease." So when the virus was finally identified as Ebola, it was already "primed to explode."
Mombouli also gives the example of Likouala Prefecture, a swampy area in northern Congo and one of the poorest, least developed regions in the country. He calls Likouala a "paradise for pathogens," rife with everything from the disease-causing bacteria treponema to the viral disease Rift Valley Fever. "You know something terrible is going to come out of that area," he says. Without proper pathogen monitoring, it's only a matter of time.
Correspondingly, Tomori thinks African countries should revamp their centralized disease surveillance systems. Surveillance shouldn't be concentrated in the national headquarters of public health agencies, he says, "1,000 miles away from where disease is occurring." He instead advocates for a decentralized, bottom-up approach where every individual stands watch over their community's health — and knows how to get help if they suspect something's wrong .
Public health agencies will still have an important role to play, empowering locals with educational programs and coordinating the response, Tomori adds. Indeed, the best early warning system might come from those living on the frontlines of novel diseases. "If you take care of that first case, you can prevent an epidemic," he says.
Mombouli has seen this work firsthand in the Republic of Congo where his team of education and health specialists have been visiting villages across the country for decades. In 2009, they conducted monkeypox outreach in Likouala Prefecture over 90 days, reaching 24,000 rural individuals. After these visits, the ability of locals to recognize at least one of the symptoms of monkeypox increased from 49% to 95% while their willingness to take a family member with monkeypox to the hospital increased from 45% to 87%, as reported in a study published in PLOS Neglected Tropical Diseases.
Mombouli's team similarly visited 268 villages in northern Republic of Congo between 2008 and 2018; they were trying to establish community-based surveillance system for Ebola. They educated locals about the virus and how it could spread through infected wildlife carcasses, emphasizing the core message: "Do not touch, move or bury the carcass and contact the surveillance network immediately."
With trust built over repeated visits, local hunters began to report the carcasses they found so that the network could test them for Ebola. The end product was a surveillance system that covered 50,000 square kilometers of the most rural regions in the Republic of Congo.
"It's not like they swallow whatever 'truths' you tell them. They ask tough questions," Mombouli says about his fellow Congolese. "But once they get it, they transmit the information and really have proper behavior." According to Mombouli, enlisting the active support and vigilance of community members can enable early disease detection and containment.
Build a 'value chain' to create needed epidemic resources
Beyond detecting pathogens early, African countries need the resources to mount a robust response against infectious diseases, from personal protective equipment to antivirals to vaccines. Unfortunately, "the medical equipment and supplies needed," the Africa Centers for Disease Control and Prevention noted in a press release, "are largely manufactured outside Africa."
As such, Mombouli thinks the continent should develop its own epidemic "value chain," a term referring to the entire manufacturing process from acquiring raw materials to distributing finished products. Presently, a few African manufacturers have experience making vaccines from start to finish, including the Biovac Institute in South Africa, which produces a hepatitis B vaccine, and the Institut Pasteur de Dakar in Senegal, which produces a yellow fever vaccine.
But building the value chain for novel health threats has proved more elusive. In the case of COVID-19, for instance, mRNA vaccine technology is a closely guarded secret.
Nonetheless, the Biovac Institute and Institut Pasteur de Dakar have begun to produce COVID-19 vaccines in Africa with fill-and-finish plants. In other words, given all the ingredients from Pfizer-BioNTech, these manufacturers fill up vials with vaccine doses and package them for distribution. Since Africa currently imports 99% of all its vaccines, this is an important step toward domestic production, says Mombouli, but he emphasizes that this model is inherently vulnerable since it's only the last step in the value chain.
"If the company decides to move out," he says, "then we go back to square one." As one concrete example, Johnson & Johnson partner Aspen Pharmacare may soon shut down its South African plant making COVID-19 vaccines because of insufficient demand due to hesitancy and difficulties distributing the vaccine (among other reasons ).
What's the solution? There's something called the hub-and-spoke model, where one "hub" aggressively develops novel vaccine technology and then freely transfers it to the "spokes," local manufacturers that can scale up production. Currently under development, this strategy adopts the philosophy that Africa's value chain must be independent of high-income countries.
Last year, WHO chose South African biotech company Afrigen to be the hub for mRNA technology transfer, and 15 spokes have since been identified across various low- and middle-income countries, including six in Africa. Although Moderna and Pfizer-BioNTech refused to share their technology and expertise, Afrigen used publicly available information to make their own version of the mRNA vaccine — one that doesn't require cold storage — and already started training the spokes. The ultimate promise, Mombouli suggests, will be African countries using novel vaccine technology to contain diseases that are spreading on the continent in particular.
Undoubtedly, this will take time, with Afrigen expected to enter clinical trials later this year and vaccine approval coming in 2024, but much can be done in the interim. Beyond fill-and-finish operations, Tomori says that African countries can identify other aspects of the value chain where they can start contributing immediately. For instance, one might manufacture glass vials, another rubber stoppers, another testing swabs and so on. Each country doesn't need to produce everything end-to-end, but Tomori says they should all be starting somewhere instead of patiently waiting for international aid.
"It is not talking; it is doing. It is not consuming; it is contributing," he adds. "If you bring nothing to the table, you get the foolish deal."
Invest in health-care workers
While community-based surveillance and building the value chain might allow some epidemic independence, Happi believes that biosecurity can only be sustained by investing in public health professionals. African countries should thus aggressively train field epidemiologists, Ph.D. scientists and frontline health-care workers — such as doctors, nurses, and midwives — "to build capacity on the ground," he says.
According to WHO's latest available data on 47 African countries, in 44 there is not even 1 physician per 1,000 people, with Niger the lowest at 0.035 physicians per 1,000. If you include nurses and midwives in the estimate, Africa's density increases slightly but only to 1.55 health-care workers per 1,000.
Part of the problem is that, of the 47 countries in sub-Saharan Africa, six of them don't even have a single medical school while 20 countries only have one. By 2030, WHO estimates that Africa will be short 6.1 million health-care workers, relative to the Sustainable Development Goal threshold of 4.45 health-care workers per 1,000 people.
But things are beginning to change. Namibia, for instance, is one of four African countries that has surpassed the WHO threshold — with 10.28 workers per 1,000.
This fledgling success stems from government prioritization. In a recent paper in World Health and Population, authors from Namibia's Ministry of Health and Social Services described how they used a WHO tool to diagnose the country's staffing shortcomings. With this data, they made evidence-based decisions about expanding nurses' scope of practice and redeploying health-care workers to the regions of most need.
Admittedly, this policy helps improve only the efficiency of Namibia's health-care system without increasing the number of providers. But in 2010, the University of Namibia established the country's first school of medicine and has since trained hundreds of practicing doctors "who can respond to the healthcare needs of the Namibian people and are advocates for the poor, underserved and marginalised in our society," according to associate dean Felicia Christians. A call from Namibia's founding president to invest 50% of the national budget in education and health care emphasizes the country's steadfast commitment to progress.
While it's critical to continue building more medical institutions, such as the Kenyan General Electric (GE) Healthcare Skills and Training Institute and the University of Global Health Equity in Rwanda, there must also be a focus on retention.
In a 2011 study in the British Medical Journal, it was estimated that sub-Saharan African countries lost $2 billion (in terms of returns on educational investment) because doctors trained on the continent moved abroad. "Africa has to look inward and start paying people the salary they deserve," Happi asserts, "so that they don't leave the continent for elsewhere." As one example, the Zimbabwean Nurses Association says that most nurses in the country earn only $53 a month, a salary lower than the World Bank's international poverty line.
While better pay might be the lynchpin, other incentives could include a mix of personal benefits and career improvements: housing, land ownership, modern equipment and pathways for professional growth, according to Kasonde Bowa, dean of Copperbelt University School of Medicine in Zambia. And if the brain drain still persists, Happi thinks that Western countries should start reimbursing the continent for its educational expenses, given that it costs African countries between $21,000 to $59,000 to train one doctor.
This wouldn't necessarily stop the exportation of health-care workers, but having the West fork over the money could help African countries replenish their workforce. "People should be honest enough to say that you cannot deplete a continent of its own resources," Happi says.
A new goal: collaboration, not just donation
Tomori sees cause for optimism in building African biosecurity: the continent already has the community leadership, natural resources and intellectual capital for change, he says. Yet these ingredients are not enough on their own: "Good governance is what we need to create an enabling environment for our people."
That's not to say African-Western partnerships shouldn't be pursued. After all, it was Sikhulile Moyo, the laboratory director at the Botswana-Harvard AIDS Institute Partnership and a research associate with the Harvard T.H. Chan School of Public Health, who first identified the omicron variant. Similarly, Happi collaborates with Broad Institute computational geneticist Pardis Sabeti, and together they deployed COVID-19 tests in hospitals in Nigeria, Senegal and Sierra Leone well before any U.S. hospital had them. Partners in Health also recently announced plans for the $200 million Paul E. Farmer Scholarship Fund, which will support students at the University of Global Health Equity in order to "educate future health care leaders in Africa."
Collaboration, not donation, is what pushes the needle forward, Tomori stressed – echoing other scientists interviewed for this story.
"There is a need for us to take those pathogens, harness the novel technologies and then translate knowledge into tools that can help not only Africa but the globe," Happi says. "Africa should be in the driver's seat when it comes to pandemic preparedness and preemption."
Simar Bajaj is an American freelance journalist who has previously written for The Atlantic, TIME, Guardian, Washington Post and more. He studies the history of science and chemistry at Harvard University and is a research fellow at Massachusetts General Hospital. Follow him on Twitter @SimarSBajaj
