LAGOS, Nigeria – Christopher Johnson was known for two things. His enthusiastic dance on the street, which made everyone laugh. And his habit of throwing insults at strangers, which constantly put him in trouble.
So when Johnson died in late September, probably from sepsis after a leg injury, according to friends, everyone in Oluti, his lively neighborhood in Nigeria’s largest city, listened.
Everyone except the government registrar responsible for registering deaths.
As the coronavirus pandemic spread across the world in 2020, it has become increasingly evident that in the vast majority of countries on the African continent, most deaths are never formally recorded. Reliable data on a country’s deaths and causes are difficult to obtain, meaning that governments can ignore emerging health threats – be it Ebola or coronavirus – and often need to formulate health policies blindly.
It is often said that Covid-19 has largely surpassed Africa. Some epidemiologists claim that their young population was less at risk; others that previous exposure to other coronaviruses gave some protection. But, like other diseases, its true toll here will probably never be known, in part because the high mortality rates cannot be used as a measure as elsewhere.
Stéphane Helleringer, a demographer who has worked with mortality in several African countries, said that on the African continent, “There are very few countries that even try to estimate mortality based on the mortality rate.”
Recently, in a local government office in Eti-Osa, a prime area of Lagos, piles of papers, records and perforated yellow birth and death certificate books surrounded Abayome Agunbiade, a registry officer at the Nigeria Population Commission.
He said bereaved residents tend to avoid his office, which is small and poorly lit, unless they need a death certificate to resolve an inheritance dispute or gain access to a pension.
“If they don’t need it, they won’t come,” said Agunbiade.
In 2017, only 10% of deaths were recorded in Nigeria, by far the largest country in Africa by population – up from 13.5% a decade earlier. In other African countries, such as Niger, the percentage is even lower.
Often, families do not know that they must report deaths or, even if they do, there is little incentive to do so. Many families bury their loved ones in their backyard, where they do not need a burial permit, let alone a death certificate.
The United Nations Statistics Division collects vital statistics from around the world. In North and most of South America, Europe and Oceania, he says that at least 90 percent of deaths are recorded. In Asia, coverage is more irregular.
But for most African countries, the UN has no mortality data.
In the absence of hard data, the researchers found other ways to estimate mortality rates.
Every few years, most African countries do research to try to capture general demographic and health trends. People are asked about who died in their families and what was the cause. But these surveys are irregular and there is a lot of room for error.
Some researchers try to find out how many people are dying by doing research on cell phones. Others count graves in satellite images or ask grave diggers, as in the 2014 Ebola outbreak in West Africa.
I asked funeral directors and coffin makers on a busy street in one of the oldest neighborhoods in Lagos, where kids from funerary bands talked, drums and trumpets under their arms. For decades, Odunlami Street has been the place for everyone who wants to buy a coffin.
Half a dozen coffin carpenters and undertakers on Odunlami Street said they noticed that business was particularly hectic in June and July.
“The morgues were packed,” said Tope Akindeko, manager of Peak Caskets, leaning on a coffin decorated with gilded reproductions of the Last Supper. The coffins he sold were cheap, rustic models, he said, while the expensive steel ones made in the United States from Batesville, Indiana, remained on the shelves.
Could it have been an increase in Covid-19 deaths? Or perhaps an accumulation of funerals, after two months of blockade in Lagos? Since few deaths are reported, it was difficult to say.
Although death may not be recorded in the public sphere, it is extremely important in the personal sphere.
In southern Nigeria, if the person being buried has reached an advanced age, funerals tend to be a celebration of life, with dancing bands and porters. Sending a loved one in style is, for many, extremely important. Colorful death notices are sent on social media and, in some areas, placed outside the homes of bereaved families, such as “For Sale” signs – containing slogans such as “Exit an icon”, “A giant sleeps” or for a younger person, “Painful exit.”
Many Nigerians said they received many more of these notices in 2020.
But Covid-19 did not hit Africa as hard as other regions, such as Europe or the Americas, at least according to official statistics, presenting a puzzle that epidemiologists have already resolved to overcome. The figures presented daily by the World Health Organization show far fewer people dying from it than the United Nations predicted in April.
In other parts of the world, epidemics have been identified by unusual spikes in deaths compared to the death rate in a normal year. Most African countries cannot do this because they do not know basic mortality.
In the absence of data, experts can make totally different claims.
“Mortality due to Covid on the African continent is not a major public problem,” said Dorian Job, the West Africa program manager for Doctors Without Borders. What he called “crazy predictions” about Covid – the United Nations said in April that up to 3.3 million Africans would die from it, for example – meant that severe blockages were imposed. The economic and social effects of this would be felt in Africa for decades, said Dr. Job.
But at the other end of the spectrum, the researchers have just declared that there was a huge and hidden outbreak in the capital of Sudan. In the absence of a good death registration system, they used a molecular and serological survey and an online one distributed on Facebook, where people reported their symptoms and had been tested. The researchers estimated that Covid-19 killed 16,000 more people than the 477 confirmed deaths in mid-November in Khartoum, which has a population about the size of Wisconsin.
Khartoum is just a city on a vast and diverse continent, with a variety of approaches to combat the pandemic. But several factors that the researchers cited as to why the number of Covid-19 cases can be largely underreported – stigma, people who can’t get tested, the fact that the threshold for reacting to any disease is high – are true in many African countries.
“Every time someone says ‘I’m so glad Africa was spared’, my toes just bend,” said Maysoon Dahab, an infectious disease epidemiologist at King’s College London who worked on the Khartoum study.
Mr. Agunbiade, the Lagos registrar, fills out a table each month telling what caused the deaths he recorded, if known. There are about a dozen categories to choose from. Old age. Malaria. Maternal mortality.
There is no Covid-19 column, although he said he sometimes crossed out the AIDS / HIV column and placed Covid. Perhaps many Africans are dying from Covid-19, but their deaths are being misidentified – just as studies have suggested they occurred at the beginning of the epidemic in the United States.
Then again, maybe not.
Ben Ezeamalu contributed reporting from Lagos.