COVID-19 threatens health systems in sub-Saharan Africa: the eye of the crocodile

The threat of coronavirus disease 2019 to health systems in sub-Saharan Africa (SSA) can be compared metaphorically to a lake in Africa infested with a bask of crocodiles and the saying "the eye of the crocodile." In the lake, only the eyes of the crocodile appear on the surface while the rest of the body is submerged in water. In this Viewpoint, the eyes and the body of the crocodile represent the public health preparedness and health systems, respectively, in SSA. SSA has had multiple epidemics, including, in the last 3 decades, HIV and Ebola virus. Interestingly, HIV, Ebola virus, and SARS-CoV-2 are all of zoonotic origin. HIV resulted from cross-species transfer of simian immunodeficiency virus from chimpanzees, found in eastern and central Africa, to humans (1). Ebola virus was discovered in humans during concurrent outbreaks in the Democratic Republic of Congo and the Sudan in 1976 (2, 3). It is believed that bats are the natural hosts of Ebola virus. SARS-CoV-2 also originated from bats found in caves in China. Although HIV and Ebola originated in Africa, SARS-CoV-2 was imported from China. This Viewpoint discusses the potential impact of the COVID-19 epidemic on already-fragile health systems in SSA and forecasts lessons likely to be learned from COVID-19 in SSA.