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Alexandra de SousaIt’s mid-June. As the virus slowly winds down in the Far East and the West, hesitatingly but for now losing ground, the pandemic is beginning to sicken the South. Overwhelmed hospitals and riots over confinement economic measures are shaking the South American nations, and revolts dominate the atmosphere in the Middle East. In Sub-Saharan Africa, the number of Covid cases is still among the lowest in the world, 1.5 cases per million, however the pandemic preparedness measures are already battering the continent’s fragile economy, hijacking its health systems, and causing countless excess deaths. In Ethiopia for example three months after the first confirmed case, the coronavirus has killed forty people but because of the restrictions in place to mitigate its spread, it is threatening more lives due to the spikes in prices of basic commodities, including food, and the increase of other endemic diseases, for which we have less hostile prevention solutions and more efficient treatments. While we wait for Covid, the collateral damage this invader is prematurely inflicting on the continent, due to its impact on the economy, the food security of the poor, and on fragile health systems underscores the need for a context-specific regional strategy.Point de dépistages (crédit : auteure)Confinement, a luxury most Africans cannot affordThroughout Africa—the world’s most rapidly urbanizing region—almost half the population lives in megacities or fast-growing towns. The potential employment opportunities provided by cities keep attracting rural migration but as demand far outpaces the rate at which job offers develop, many urban migrants are forced to engage in informal economic activities, and resort to living in slums or shanty towns. More than half of Africa’s urban citizens live in slums where abiding by the directives for regular hand washing with soap and keeping physical distancing is unrealistic ((https://mirror.unhabitat.org/downloads/docs/4626_83992_GC%2021%20Africa%20on%20the%20Move.pdf)) (( https://reliefweb.int/report/kenya/water-handwashing-slums-critical-prevent-covid-19-spreading)) (( https://www.gavi.org/vaccineswork/how-do-stop-spread-pandemic-slum)). Confinement as a measure to contain the virus transmission is another luxury that most Africans cannot afford. Slum residents in Kenya’s capital, while under lockdown, were for the most part leaving their homes an average of three times a day. Their biggest unmet need was food, and in the first month many were already missing meals or eating less. Hence, the current prescribed measures present an insurmountable challenge to the continent. In the absence of other interventions, it is becoming apparent how SARS-Cov-2 will continue to circulate in these dense urban settlements, and Africa’s slums risk becoming its next natural reservoir.&#160;Meanwhile, as the continent prepares to fight COVID-19, key achievements made over the past decades on the reduction of poverty and hunger, two landmarks of world progress, are becoming seriously endangered. Sub-Saharan Africa has the largest informal job sector in the world. This workforce that lives hand-to-mouth, and for whom staying at home is not an option, will be the first and the most affected by the economic measures to contain the virus, and among the most exposed to the virus itself. Current projections for the continent estimate that the economic impact of the restrictive measures risk pushing back an additional 130 million people into food insecurity, and another 40 to 60 million people into extreme poverty. Should these projections materialize almost all the progress made in the last five years will be erased. In addition, disproportionate poverty and malnutrition will likely lead to excessive morbidity and mortality of COVID-19, which without active interventions perpetuates a tragic vicious cycle.Corvée d'eau (crédit: auteure)By April, 42 of the 55 nations in Africa had imposed a partial or full lockdown on the movements and activities of their people, but within a few weeks of confinement the economic cost started exacerbating poverty, threatening lives, and triggering riots. Outbreaks of panic buying dominated northern Nigeria as food prices continued to rise due to shortages in supply caused by limitations on transport. And even as countries eased their movement restrictions, not much calmness returned because food supplies remained limited and prices of basic commodities stayed on the high. Civil disobedience has also occurred when governments introduced harsh measures to enforce lockdowns. Africa’s COVID-19 crisis threatens to become not only a health and economic emergency, but one defined by multiple humanitarian and security crises. How long can the poor habitants of the African slums remain locked down with restricted access to livelihoods and food before they resort to riots and other demonstrations of civil unrest? While the region’s gross domestic product risks a 2.5 per cent reduction every month due to the containment measures, the virus transmission is nevertheless growing at an average of 30 per cent a week. These excruciating tradeoffs are pushing many governments to ease the measures and consider lockdown exit strategies. Cognizant of how the lack of access to food can inflame tempers and galvanize uncontrollable violence, governments started redirecting substantial resources to support vulnerable families and communities. Existing safety nets, such as the Ethiopian productive safety net, that support poor rural communities and have already significantly contributed to the reduction of poverty and hunger, must be urgently scaled up particularly in urban slums in order to protect the poor from the virus and the confinement. The success of this mitigation strategy will largely depend on the robustness of these safety net measures.Diminution de la consommation d'essence du fait de la baisse de circulation des personnes et des marchandises (crédit: auteure)The collateral damage of COVID-19 on Africans’ healthEqually distressing is the premature impact COVID-19 preparedness is having on other epidemics. While the virus is still emerging in Sub-Saharan countries, other endemic diseases that were left unattended have not waited to flourish. COVID-19’s impact in the region will likely factor a much higher number of additional excess deaths if this trend continues, or if there is a decrease of health care seeking when we reach the peak of the epidemic. The indirect impact of COVID-19 on other endemic diseases in the region has been extensively modeled. Some estimate we could see deaths related to HIV, tuberculosis and malaria increased by 10, 20 or 36 percent, respectively, over the next five years. With respect to malaria for example, nearly 90 percent of whose deaths occur in Sub-Saharan Africa, the current pandemic poses the single greatest threat to global efforts to reduce its burden. This mosquito-transmitted disease is largely controlled by insecticide treated bed nets. However, the distribution campaigns of bed nets are now at threat due to restriction of movements and the cancellation of community gatherings. Should these campaigns be scaled back we may see the burden of malaria more than double, and when COVID-19 peaks on the continent, if malaria treatments aren’t available, we could go back to the levels of mortality last observed 20 years ago.Likewise, if the observed trends of COVID-health-system sequestering continue, the gains made in preventing HIV mother-to-child transmission will also be reversed and lead to a dramatically increased incidence of new HIV infections among children, which in some countries like Uganda could more than double. Similarly, disruptions of up to 6 months of antiretroviral therapy could lead to more than half a million additional deaths from AIDS-related illnesses, including tuberculosis, in Sub-Saharan Africa alone ((https://doi.org/10.6084/m9.figshare.12279914.v1)) ((https://www.who.int/news-room/detail/11-05-2020-the-cost-of-inaction-covid-19-related-service-disruptions-could-cause-hundreds-of-thousands-of-extra-deaths-from-hiv)) ((https://www.imperial.ac.uk/media/imperial-college/medicine/mrc-gida/2020-05-01-COVID19-Report-19.pdf)). This scenario would reverse the clock on gains made in the fight against HIV as far back as 2008. And the list continues. Twenty-four countries in Africa have already delayed measles’ immunization campaigns because of the coronavirus pandemic, and thirteen countries may not implement their campaigns this year. Measles is a highly infectious and deadly disease, for which an efficient vaccine exists that has prevented 32 million child deaths in the last 20 years. Other immunizations are equally at risk. Yet, missing routine immunization programs due to fear of contracting COVID can cause about 140 excess deaths in children due to incomplete childhood immunization for every single prevented excess death due to a SARS-CoV-2 infection acquired during vaccination visits. In addition, we are yet to learn if the debilitating impact on the immune system that these preventable and treatable diseases cause will contribute to the development of yet more severe forms of COVID-19. Dessin sur photo de Paulo Braga et d’Alexandra de Sousa.  intitulée « low lands&#160;»  Hidden opportunities to be exploredAfrica has been dealing with these afflictions through the establishment of symbiotic systems, integrated into communities, and supplemented with additional campaigns. The dismantling of these efforts will be a huge toll for Africa’s fragile health care systems. Instead COVID-19 management could be used synergistically as an opportunity to improve malaria and HIV control, as well as routine immunizations, and hasten the elimination of many of Africa’s endemic diseases. These grim prognoses are neither unexpected nor new. It would be inexcusable if the lessons of other SARS outbreaks and the West Africa Ebola outbreak (where health care services were so dramatically reduced that the excess mortality observed was several times higher than the one caused by the viruses themselves) were to be ignored. Ironically, most of Africa’s endemic communicable diseases have either efficient vaccines or treatments or both. They also have systems in place to prevent or treat them. These are considerable advantages over COVID-19 as of now and should not be discounted.As coronavirus progresses in Africa, we will soon know if these somber projections materialize or if, behind this apparent insurmountable challenge, there are hidden opportunities to be explored. The overall human cost of COVID-19 in Africa has not been fully considered, and perhaps the worst-case forecasts will not materialize, but instead lead to solutions that we have yet to grasp. Perhaps it is true that all the dragons in our lives are indeed princesses who are only waiting to see us act (( Rilke, R. M. Letters to a young poet, 1903.)).Disclaimer: This paper contains only personal opinions, advice, and statements. It does not represent in any way the opinion of the any institution or organization, including that of the United Nations. It’s potential inaccuracies, errors, or omissions, are the sole responsibility of its author.