At the start of the COVID-19 pandemic, experts warned of catastrophic consequences for African countries. Yet African countries still appeared relatively unscathed compared to countries in other regions by the end of 2021, sparking discussions of an “Africa paradox” where Africans had escaped the worst consequences of the pandemic. However, closer examination reveals a very different narrative.  

In “The Missing Millions: Uncovering the Burden of Covid-19 Cases and Deaths in the African Region,” published in Population and Development Review, we highlight myths and misconceptions. Contrary to initial impressions, multiple sources of evidence clearly demonstrate that Africa did not escape the negative consequences of the pandemic. Serological studies conducted across various African nations indicate infection rates comparable to, or even surpassing, countries in other global regions. The discrepancies between recorded cases and seroprevalence, which are widest in African countries, highlight the inadequacies of surveillance systems and underscore the need for more comprehensive data collection strategies. 

Many commentators presented the idea that Africans infected with COVID-19 were less likely to die from the disease. Official COVID-19 death tolls in Africa may appear lower than in other parts of the world, but this discrepancy masks underlying realities. Across multiple metrics (infection fatality rates, case fatality rates, excess deaths) we find consistent patterns of substantial or even greater mortality impacts of COVID-19 in African countries compared with other global regions. These findings are supported by local studies tracking morgue and burial site usage.  

The size of the gaps between reported cases and seroprevalence, as well as between reported deaths and excess deaths, varies across African countries. However, there is a notable convergence in nations with more robust healthcare and vital registration systems. Evidence suggests that COVID-19 patients in African hospitals faced higher mortality rates due to insufficient critical care resources. Additionally, contrary to expectations, the younger population structure did not offer significant protection, mainly due to discrepancies in healthcare access. These factors largely account for the disparities between official COVID-19 figures and estimates derived from population-based seroprevalence studies, as well as between reported deaths and estimated excess mortality rates. 

Our findings underscore the urgent need for a more equitable distribution of healthcare resources and enhanced disease surveillance across Africa. Strengthening civil registration systems, investing in healthcare infrastructure, and bolstering healthcare capacity are imperative steps toward mitigating the impact of future pandemics. The false narrative of an Africa unscathed by the COVID-19 pandemic has likely limited demand, investment in, and timely delivery of vaccines to Africans, which has almost surely increased the burden of COVID-19 infections and deaths, given the effectiveness of COVID-19 vaccines at preventing severe disease and death.