Nearly two-thirds of Africans may have contracted the coronavirus, the W.H.O. says.

From The New York Times, I’m Sabrina Tavernise. This is The Daily.

Throughout the pandemic, as countries have struggled with disease and death, one part of the world seems to have been mysteriously spared— Central and Western Africa. My colleague, Stephanie Nolen, traveled to Sierra Leone to investigate why that is and what it tells us about the future of the pandemic.

It’s Thursday, April 7.

So, Stephanie, you’re a global health reporter at The Times. Tell me about the kind of reporting that you’ve been doing during the pandemic.

So, generally, a global health reporter looks at the big health problems that cut across regions of the world, things like infectious disease, malaria, tuberculosis, H.I.V. But of course, in the Covid era, that’s mostly meant reporting on Covid. And I’ve been doing a lot of reporting in particular on vaccination and on the efforts to try to vaccinate the world. And in February, I took a trip in Sierra Leone where I was hoping to figure out what was happening in some of the least vaccinated countries, and also to do some reporting on some of the other issues we haven’t paid as much attention to in the pandemic.

So I arrived in Freetown, the capital of Sierra Leone, at what was the height of the Omicron wave. And I was coming from Canada, which was a country really in the grip of another wave of the pandemic. And I hired a vehicle with a driver, and I kitted it out with masks and hand sanitizer and rapid tests. And we headed up to the northwest of the country the first day I was there, and it was really startling.

We saw there was a big rock concert in the town where we were staying. There was a big football tournament with people packed in to watch it. Nobody had a mask on. And it really seemed like Covid was just not a thing people were thinking or talking about at all when I would ask people, are you worried about Covid? I mean, they knew what I was talking about, but they couldn’t fathom why I would be concerned. It was like time travel back to 2019, like I had landed in a place before Covid somehow.

And right away, I thought, I need to understand what’s happening here. Is it that Covid for some reason is just not here? Or it is here, but it’s not making people sick? It’s not killing people? And I had been reading debate about this in journals for months, this question of what was happening with Covid in Africa, but until I saw it, I really didn’t understand just how puzzling this was. And I very quickly decided to put aside some of what I had come to Sierra Leone to report on to try to really dig into this mystery.

Stephanie, to that point, what’s the big picture here? I mean, tell me what’s been happening in different parts of Africa during the pandemic. Catch me up on how it’s played out.

So I’ll start with South Africa because that’s the country in sub-Saharan Africa that we know the most about. So South Africa, of course, has had a pretty rough time. The Beta variant was first identified there. The Omicron variant was first identified there. They’ve caused bad waves. We know that there have been probably 300,000 deaths caused by Covid in South Africa.

As you move through the continent, it gets murkier. East Africa has reported some bad waves in countries such as Kenya, Uganda. There have been reports of people having to leave bodies outside hospitals because the morgues were full. But they’re rare stories. And as you move into Central and then Western Africa, there have been even fewer reports like this, right? Much, much lower reports of deaths. Sierra Leone is a country of 8 million people, and they’ve reported a total of 7,700 Covid cases and just 125 deaths.

That seems incredibly low.

It really is.

So how did you start to answer that question, Stephanie? The question of why Sierra Leone seemed less affected by Covid. What did you do first?

So the first thing I wanted to try and understand was what was happening with cases. And the town that I was in, Kamakwie, happened to have the regional Covid coordinator’s office there. So I went across town and walked into the office.

And it was completely empty, except for the district coordinator, the Covid coordinator, who I found sitting behind his desk, all alone in an otherwise completely empty office. He had a shiny new laptop in front of him, but no internet connection and, indeed, no power. And when I asked him what he knew about cases, he told me really proudly that they’d only had 11 since the start of the pandemic.

Oh, wow, 11 for roughly what kind of population?

Oh, it’s about 125,000 people in this district.

Wow.

So that was kind of shocking. But then the question was, well, how do you know? So I asked him what was happening with testing. And he said the testing was happening over at the hospital. So I went from there a couple of miles away to the hospital, thinking, OK, maybe somebody else can tell me more about testing.

This is the hospital of the same region?

It’s the district hospital serving those 125,000 people. And there was a lab, and there were three busy technicians in that lab. And when I said, what are you doing in terms of Covid testing, they were pretty blunt. There’s not a lot of resources in this hospital. So what they do when people come in is they triage. They test first for malaria. And if you don’t have malaria, they’ll test you for typhoid. And if you don’t have typhoid, then they’ll test you for Covid. And so they never really need to test anyone for Covid because before they get to that point, they figured out what they have.

So, Stephanie, it sounds like from your reporting what you’re finding is that, number one, the regional coordinator is not doing the testing. And number two, at the hospital, they have so many other urgent diseases, malaria, for example, that Covid is just really the last thing on their list.

Exactly. There was no way talking to these regional authorities that I was going to be able to get a good sense of the actual scale of Covid infection in the country. So I went back down south to Freetown, to the capital. And I went to see Dr. Austin Demby, who is the health minister of Sierra Leone. And I went into his office in the ministry.

And told him why I was in Sierra Leone.

And he told me about how he used to work for the C.D.C. in the United States. And he came home just a year ago to take up the job of minister.

And that was peak pandemic. So no vaccination had happened in Sierra Leone at that point. But also—

—just a couple of days after Dr. Demby came back to take up this job, an Ebola outbreak was declared.

Oh, wow.

So this is a guy who really knows a thing or two about pandemics.

And we started off by talking a little bit about 2014, ‘15, ‘16, when that last really terrible Ebola outbreak, you might remember, went through this region. 11,000 people died. It was really devastating for Sierra Leone.

And so they had all that to draw on when they first got the news about Covid.

And when I started asking Dr. Demby about Covid, he attributed some of their low case numbers to the fact that they’d been able to very quickly mount a strong response.

But then how does Dr. Demby explain the things that you were seeing in your reporting, Stephanie? I mean, in the regional coordinator’s office, in the hospital, this fact that people didn’t seem to be doing any testing.

Right, so I asked him about that.

I said, what do we actually know about how much Covid there is here? How much are you testing? How much are you looking?

And he acknowledged freely that there’s very little testing happening.

So it sounds like the health minister of Sierra Leone is confirming the theory that cases are being severely undercounted.

Yeah, definitely.

And in fact, he told me about some recent research that had looked for antibody levels in the population and had found that probably half the people in Sierra Leone when that study was done had already been exposed to Covid.

And Stephanie, is there other data to back that up?

Well, there is, actually. There’s really interesting data from the World Health Organization that just came out that shows that two-thirds of people across sub-Saharan Africa have Covid antibodies. There’s other data sources, looking particularly at West Africa, that show that 75 percent of people have got Covid antibodies. And remember, when these studies were done, only 3 percent, 4 percent, 5 percent of people had had access to vaccination. So if you’ve got antibodies, it’s because you had an infection.

So that kind of answers your original question, right? Clearly, a lot of people in Sierra Leone did have Covid.

Yeah, absolutely. And in fact, Dr. Demby said this to me pretty much point blank in our conversation. They know lots of people have been infected.

But he also talked about something else they’re seeing— or actually, what they’re not seeing. He was just totally adamant that they’re not seeing the death rates that we’ve seen in other parts of the world.

And remember, Sierra Leone has this surveillance system that’s a legacy of that terrible Ebola outbreak.

And he says, look, if there was a spike in deaths in one region of this country anywhere, we would know about it, and it’s just not happening.

Hmm. Interesting. So it sounds like, Stephanie, from what you’re saying, Sierra Leone and a lot of sub-Saharan Africa reported really low case counts during the pandemic. But data suggests that a lot of people actually have the antibodies, had Covid. And if we follow what happened in the U.S., they should have a lot of deaths, right? But what the health minister is telling you is that very few people in Sierra Leone died.

Well, so there I am with a whole new mystery, right? If lots of people have Covid, but they don’t have deaths to report, what’s going on?

We’ll be right back.

So, Stephanie, how did you go about digging into this other part of the mystery, which had to do with how many people in Sierra Leone actually died of Covid?

So I started calling up epidemiologists in all different parts of sub-Saharan Africa, people I’ve known for a long while. And I started asking them this question of, what do you think is happening? And after a lot of conversations, I kind of was left with two really different theories that would explain how even though we know there are lots of Covid infections in Sierra Leone and other countries in the region, how it could be that people don’t seem to be dying.

And what are those theories? Lay those out for me.

Well, the first one is that there is no mystery. There’s just lousy data on deaths. There’s not some miraculous thing happening in West and Central Africa or in regions that report lower Covid deaths. The reason that they would be reporting fewer people dying of Covid is just that we do a really bad job of counting them. And the second theory is that, in fact, there’s no way that thousands and millions of deaths have been missed. Something else is protecting people. Something else is going on that means people are getting infected with Covid, but they don’t get sick or they don’t die at the same rates.

OK, so let’s start with the first theory because that one seems pretty logical to me. I mean, if it’s clear that cases were being undercounted, then probably deaths were being undercounted, right?

Yeah, I think this is a really strong argument. We know that death registration in much of sub-Saharan Africa is really, really poorly done. There are a lot of countries where only 5% or 6% of deaths are ever registered with a civil authority.

Oh, wow.

People don’t typically die in medical facilities or hospitals. They most often will die at home. And they get buried in a small village graveyard. And so that death never gets reported. An excellent Zambian public health researcher I spoke to told me about a study he’s been doing that found that nearly 90% of the bodies in the main morgue in Zambia were positive for Covid.

This was at the height of the Delta wave. And he said, look, there’s just no reason to think that fewer Zambians would be dying or Ethiopians or Sierra Leoneans, right? There’s no inherent reason why there would be fewer deaths here, just the record keeping is really weak.

And there’s a model that draws together lots and lots of different data sets that the economist has been running that says there could be up to three million Covid excess deaths in sub-Saharan Africa.

Oh, wow. So three million deaths that basically have been uncounted.

That’s the argument. Now, look, to be clear, that model says the deaths have been undercounted all over the world. We know that that’s true. But according to this model, the problem of undercounting is the most severe in Africa.

And does that hold water?

Well, a lot of people that I spoke to say there’s no question some deaths have been missed, but they’re really not buying it. And that includes the chief of the Covid response for the W.H.O., the World Health Organization in sub-Saharan Africa. He said to me there’s just no way, there’s just no way that we have missed millions of deaths. Models are useful to a point, but there are lots of other ways of seeing deaths, right?

When Zambia had a bad Delta wave, there were bodies stacked outside the morgue. I mean, a place like Sierra Leone holds really, really big funerals. People say there’s just no way that there could be hundreds of thousands or even millions of deaths and that we’ve just missed them.

And Stephanie, if it were true that there were high case numbers, but low deaths from Covid in Sierra Leone, what would explain that?

Well, that is an excellent question. So, again, there are lots of theories. The leading one— and I think that whatever else is true, this is a part of it— is age, right? Sub-Saharan Africa has a median age of 19, right? Sierra Leone is right around that as well. And that compares with 43 in Europe, 38 in the United States. And so we know that Covid is much more deadly for older people who have lived long enough to have developed the co-morbidities, such as diabetes, that makes Covid really deadly. The virus is far less likely to kill young people. And they’re often asymptomatic altogether.

Another argument that I heard quite a bit had to do with temperature, the fact that it’s, obviously, really quite warm in all of these countries, and people mostly live their life outdoors. Obviously, if you’re talking about people who are in Sierra Leone, primarily subsistence farmers spending the day in their fields, they’re not getting exposed to Covid the way they would on a crowded subway train, although, of course, now we know that huge numbers of people actually have been infected. So that theory is a bit questionable.

And then finally, the last argument that I heard quite a bit had to do with other pathogens that people have either been exposed to so many other coronaviruses that they had protection against Covid, or just that if you make it into adulthood in a place like Sierra Leone, you’ve had repeated bouts of malaria. You’ve been exposed to lots of other infectious disease, that maybe people just have a level of immunity that has helped blunt the effect of Covid.

Hmm. That’s interesting. And how do these three factors hold up when you compare Sierra Leone to another similar country that had a really bad time with Covid?

Well, we can talk about India. India has reported half a million Covid deaths, but it’s pretty widely accepted that the real number is probably closer to 4 million people who’ve died of the virus. So India also has a young population, right? There, the median age is about 28. It’s also a really warm place where much of life is lived outdoors. And there’s regions of India that have very high rates of infection with malaria. There are lots of other pathogens in circulation, so people would have had prior exposure to lots of things.

So we know that those factors were not protective in India. On the other hand, India is a much more dense place. It’s much more connected. It has much better transportation. So it’s not a straight comparison to Sierra Leone, but it’s enough to suggest that those three things alone don’t cover it as an explanation.

So it sounds like what India is showing us is that these factors you’re talking about, they’re all playing something of a role, but there’s not a single one of them that solves the mystery entirely.

Yeah, that’s exactly right.

So I’m wondering, Stephanie, in all the reporting you’ve done, how do you even begin to figure out what’s true? I mean, is it that Covid deaths in Africa are really being undercounted, or that Africans have this really unique immunity to Covid?

Where I wound up is that the truth is probably somewhere in the middle. If you’re in a place like Sierra Leone that has incredibly high infant mortality— it has the highest maternal mortality in the world. Thousands of people die of malaria. There is all kinds of other infectious diseases that people are prey to. It is possible that Covid could cause a rise in the number of deaths that wouldn’t necessarily show up the way it would in a country with overall lower mortality figures.

On the other hand, I believe people in Sierra Leone when they say to me, there have been no extra deaths in my village this year. One person died, two people died. It’s just like all the other years. Nothing unusual has happened here.

Right.

What I can also tell you is that I was able to sit down and read all of the serious research on the topic in a single morning. It’s not getting anywhere near the level of attention that I feel like it should because it really matters, right? It matters for Sierra Leone, for sub-Saharan Africa, but it also matters to everybody else.

What are the stakes, Stephanie? Why does it matter?

Well, it matters for a couple of reasons. In terms of why it matters for the world, if there is something going on that means people really aren’t getting sick with Covid or aren’t dying from Covid at the same rate in West and Central Africa, in sub-Saharan Africa as a whole, understanding where that protection, where that immunity is coming from, that could help us in lots of ways. It could help develop better treatments. It could help with another generation of vaccines.

So it matters for protecting the world, but it also matters for sub-Saharan Africa, for Sierra Leone. There is a goal from the World Health Organization and the African Union to vaccinate 70 percent of people. And Sierra Leone is scrambling to do that.

When I spoke to the health minister, Dr. Demby, he was talking about how there’s a lot of resources coming into the country right now to do Covid vaccination. But—

That is an enormous challenge in a place like Sierra Leone with a health system that was already really struggling to respond to what people needed.

And then trying to convince young healthy people to get a shot for a disease that, as we’ve just been talking about, they really don’t think as a risk to them.

So it sounds like there’s this tension here, right? I mean, public health authorities have been trying to vaccinate 70 percent of Africa. But Dr. Demby is finding that that’s a really complicated thing to do, and especially complicated when it’s not even clear how much of a threat Covid is to this country.

I think there’s a growing— it started as a whisper and then a mutter, and now it’s a kind of out loud conversation about whether getting to 70 percent in sub-Saharan Africa makes sense, whether pouring resources into vaccination in a place like Sierra Leone really is the best use of those resources.

I think all things being equal, Dr. Demby would really like for his people to be protected from Covid because even if the virus isn’t killing people now, the next variant might be deadly. But—

He also has hospital wards that are full of people with malaria and the highest maternal mortality rate in the world. And because Sierra Leone gets nowhere near the amount of support that it needs to try to build a really functional health system, he’s facing these trade-offs. I would say there are artificial trade-offs between addressing one disease or another. And so he’s in this position where he’s having to really ask himself, what should he do with the limited resources that he has?

Stephanie, thank you.

It’s a pleasure.

We’ll be right back.

Here’s what else you need to know today.

On Wednesday, in response to atrocities in the war in Ukraine, the United States and its allies moved to impose full sanctions against Russia’s largest financial institutions.

The Biden administration, together with the European Union, imposed strict sanctions against Sberbank, the largest financial institution in Russia, which holds over a third of the country’s financial assets, and Alfa-Bank, one of the country’s largest private banks. The administration also announced that it would block access to U.S.-held financial assets for family members and close associates of Russian President Vladimir Putin, including Putin’s two adult daughters.

And Pentagon officials said that Russia has withdrawn all of its troops from the territory around Kyiv, Ukraine’s capital, and Chernihiv, a major city in the north. Russia said it would do so more than two weeks ago, but Pentagon officials had expressed skepticism that the self-proclaimed pullout could be a ruse. As many as 40,000 Russian troops have now left the territory and are rearming and resupplying before launching what Western officials believe will be a renewed focus on Ukraine’s east and south.

Meanwhile, a video posted online and verified by The New York Times appears to show Ukrainian mistreatment of Russian prisoners. In the video, a Russian soldier can be seen with a jacket pulled over his head, gasping for air, before he is shot by a Ukrainian soldier. At least three other men believed to be Russian soldiers lay dead beside him, one with his hands tied behind his back.

Today’s episode was produced by Rachelle Bonja, Rikki Novetsky and Rob Szypko, with help from Michael Symon Johnson. It was edited by Anita Badejo, contains original music by Marion Lozano and was engineered by Chris Wood. Our theme music is by Jim Brunberg and Ben Landsverk of Wonderly.

That’s it for The Daily. I’m Sabrina Tavernise. See you tomorrow.