When Dr. John Nkengasong took the job as the first head of Africa’s new Centers for Disease Control in 2017, part of the continent had just emerged from a devastating Ebola outbreak. Less than three years later, Covid-19 hit.
Dr. Nkengasong is now trying to bring together the governments of a vast, diverse continent to anticipate and fight public health threats and make them less reliant on international institutions like the World Health Organization or the Red Cross. He has helped Africa speak with a unified voice, particularly about what he calls “vaccine famine,” with rich countries buying up millions of doses they do not need while Africa goes wanting.
Perhaps Ebola was a signal that something bigger was looming, he says, and that something turned out to be Covid-19. He also thinks Covid-19 could be a harbinger of something worse to come: a virus as contagious as the Delta variant but with the high fatality rate of Ebola.
The Africa C.D.C. was started in response to the Ebola outbreak, with funding from the African Union and some other donors. When Dr. Nkengasong arrived, for months there was no office, no staff and even at one point no internet; the Ethiopian government had shut it down to prevent people from cheating on university entrance exams.
But, he says: “We can do public health under the tree. It doesn’t really matter. The thing is the concepts. Are you committed to solving problems of inequity and health security?”
(This conversation was edited and condensed for clarity.)
What was it like when Covid-19 first hit the continent?
In December 2019 I was on leave, and we started hearing stories on the virus in Wuhan. I called Addis Ababa and said, “Activate our Emergency Operations Center.” I got initial pushback from my own staff. They said, “Well, this thing is happening far-off. We have Ebola going on in North Kivu.” They said, “We already are too busy.” I said, “Please, just do it, because I know that this will come.”
The continent started off well. We’d positioned ourselves. We scrambled. We trained people. It will sound ridiculous, but at the first trainings we did in South Africa and Senegal, everybody went home with a pack of 100 tests.
How are things going now? And how do you see the virus’s future trajectory in Africa?
An emergency is where your house is on fire. You run around, you call 911, they come sprinkle water. That phase is over. We are now in a phase where your house is burned down. How to build a new house?
I think this virus is winning. As a continent, we are not winning. Today we have more than seven million cases with close to 180,000 deaths. And the death rates are all increasing very dramatically across the continent. Vaccination rates are very, very low. We are around 2.5 percent of the population vaccinated fully, and this is a continent of 1.2 billion people.
What about vaccines for African countries? Is Covax — the alliance backed by the United Nations — coming through as promised?
The story of access to vaccines and the role Covax was supposed to play is what I call a moral tragedy.
The intent and the design was perfect, excellent, but the execution — even the people running Covax will admit that it has not delivered on its promise.
Those countries that are funding Covax, or pledged funding, were developed countries. So they pledged. I’m not sure that they necessarily gave money. But then, they bought the vaccines, all the vaccines. So even with the money that Covax had, there was nowhere to get vaccines from.
We are not saying, donate to us. Don’t give us the vaccines. We’re just saying, let Africa come forward with their 400 million doses of vaccines — that they have paid for! By just swapping the order in which we are in the queue for vaccine delivery, I think you can begin to solve a lot of the problems.
What is the condition of Africa’s public health infrastructure?
Governments have not invested enough in their own public health needs.
The whole architecture — public health architecture and health security architecture — has been designed, since the Second World War, in such a way that they created a lot of dependency, Africa on the outside world.
Africa has about three million health care workers. That is almost nothing. So you clearly see the negligence. And our health security architecture was designed when the population of Africa was less than 300 million. Today, where are we? We are 1.2 billion people, aspiring to get to 2.5 or 2.4 billion in the next 30 years.
No people will survive with importing 99 percent of their vaccines and importing 100 percent of their diagnostics. It doesn’t make sense. We need 6,000 epidemiologists. We currently have only about 1,900 on the continent.
Are people hesitant to get vaccinated?
It still has to be a battle that is won or lost at the community level. Misinformation continues to be a serious issue.
However, when I look at the trends, what is happening on the continent, I’m very encouraged. I was in Morocco, and at the Tangier sports stadium you had long lines of young people. When I approached them, I thought there was a soccer match going on, but it was people registering online to get the vaccine. We’ve seen similar scenarios in Kigali, in Nairobi.
So vaccine hesitancy is no longer the issue. Vaccine famine is the real challenge now, not vaccine hesitancy.
What is your goal for vaccinations in Africa by the end of 2021?
It was to get to at least 25 to 30 percent by the end of the year. But that would be dependent on many factors. Are countries that have secured vaccines ready to release those vaccines?
At the pace we are doing it, we are very deliberately moving toward endemicity of this virus on the continent, no doubt about that. Now it’s concentrated in big cities, but it will soon spread into remote areas, and it becomes very, very difficult to flush out.
You worked for the U.S. Centers for Disease Control for many years. What was it like moving back to Africa?
I grew up in Cameroon. You leave and you think you’ll go back, and then life carries you on from one part of the world to another and you just keep going.
Understand Vaccine and Mask Mandates in the U.S.
- Vaccine rules. On Aug. 23, the Food and Drug Administration granted full approval to Pfizer-BioNTech’s coronavirus vaccine for people 16 and up, paving the way for an increase in mandates in both the public and private sectors. Private companies have been increasingly mandating vaccines for employees. Such mandates are legally allowed and have been upheld in court challenges.
- Mask rules. The Centers for Disease Control and Prevention in July recommended that all Americans, regardless of vaccination status, wear masks in indoor public places within areas experiencing outbreaks, a reversal of the guidance it offered in May. See where the C.D.C. guidance would apply, and where states have instituted their own mask policies. The battle over masks has become contentious in some states, with some local leaders defying state bans.
- College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.
- Schools. Both California and New York City have introduced vaccine mandates for education staff. A survey released in August found that many American parents of school-age children are opposed to mandated vaccines for students, but were more supportive of mask mandates for students, teachers and staff members who do not have their shots.
- Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get a Covid-19 vaccine, citing rising caseloads fueled by the Delta variant and stubbornly low vaccination rates in their communities, even within their work force.
- New York City. Proof of vaccination is required of workers and customers for indoor dining, gyms, performances and other indoor situations, although enforcement does not begin until Sept. 13. Teachers and other education workers in the city’s vast school system will need to have at least one vaccine dose by Sept. 27, without the option of weekly testing. City hospital workers must also get a vaccine or be subjected to weekly testing. Similar rules are in place for New York State employees.
- At the federal level. The Pentagon announced that it would seek to make coronavirus vaccinations mandatory for the country’s 1.3 million active-duty troops “no later” than the middle of September. President Biden announced that all civilian federal employees would have to be vaccinated against the coronavirus or submit to regular testing, social distancing, mask requirements and restrictions on most travel.
I remember when I took the job, my colleagues said, “John, maybe you’re going through a midlife crisis? Why would you leave Atlanta and leave your job, and go and start something that you really don’t know?” But it was in me that I had to do that.
For almost a year, I didn’t have an office. I had a big name of a director, but there was no place to sit and work.
Has it been easy? Not at all.
The moment you say you have a C.D.C., the expectations are very high. Especially borrowing a name from a renowned C.D.C. like the U.S. C.D.C. put a lot of pressure and expectation on our shoulders very, very early on.
Does public health in Africa need to be decolonized?
Shirley Chisholm said that if they do not give you a chair around the table, go there with a folded chair. Don’t ask for permission to do what is your right.
Imagine, the first conference on public health in Africa will be organized by Africa C.D.C. at the end of this year.
Why is that important? It provides a platform for African public health experts to interact, share experiences, learn from each other.
Second, is that we invest in our own schools of public health and believe in our own schools of public health.
Learning a lesson is what Africa is currently doing; we don’t have vaccines, we have to produce vaccines.
If we continue on this journey driven by a new public health order, when the next pandemic hits, we’ll be fighting it very, very differently.