Covid-19 is not the first pandemic that Dr Matshidiso Moeti, the first woman to hold the World Health Organization’s top role in Africa, has battled. In her early years working at a hospital in Botswana in the late 1970s, HIV began its insidious creep across the nation.
“If you can picture Botswana at that time,” she says, “the country had discovered diamonds, it was growing, this was a very well-regarded, democratic country, very clean, very little corruption. And then this HIV hit.” Botswana rapidly became the worst-affected country on the continent, with prevalence among sexually active people of more than 30 per cent and around 33,000 new infections per year by the mid-1990s. “I just remember feeling helpless and furious,” says Moeti.
But her experience meant that as Covid-19 emerged, she had the skills and expertise to lead what has been a world-beating response across the continent. Moeti has worked with leaders to steer the region through the throes of Covid-19, holding a steady course that has stunned many observers who expected the continent would suffer a worse fate.
“We did a lot of work to prepare precisely because of the worry that our health systems are so fragile, our capacity is so little, we will get devastated by this,” says Moeti, 66, speaking over Zoom. By December, Africa, which makes up 17 per cent of the global population, had recorded just 3.5 per cent of Covid-19 deaths, and fewer overall than the UK alone.
Public health experts say that Africa’s experience of devastating bouts of infectious disease stood leaders in good stead when it came to recognising and responding to the imminent danger posed by coronavirus.
Moeti’s career in public health, which has spanned four decades and four epidemics (tuberculosis and Ebola as well), has often centred around educating and empowering women. They tend to bear the brunt of infectious disease because of what she describes as financial and social iniquities, some of which she has personally experienced.
Born in South Africa in 1954, the daughter of doctors, Moeti recalls her early years under apartheid, which not only separated racial groups but minutely regulated their behaviour. She could not buy items from certain shops and her house was ransacked by the government after someone had told it her father owned the wrong kinds of books — “the sort that tell you people are equal and a racist system like this is not normal”.
“One learnt as a child that there’s something wrong here, there’s some injustice going on, this is not OK,” she says. “[For] people who are vulnerable because their economic status, their social status, their ethnicity is different, it really has an impact on people’s lives and people’s health. Just look at Covid-19 and who it’s impacting in the US, in the UK.”
Moeti moved from primary school in a small South African township to a boarding school in Swaziland, which was a British colony “with a different and better education system”, but travelling across the border to get to school was a “massive struggle”, including hostile interactions with police. When she was 11, her parents decided to move to neighbouring Botswana in search of a less onerous way to educate their children.
After school, Moeti spent some years working in a district hospital, before studying public health at the London School of Hygiene and Tropical Medicine. After her course, she returned to Botswana to focus on the terrible lung problems faced by men working in the mines. But it wasn’t long before HIV ravaged the country and her career was diverted.
When that pandemic hit, Moeti worked with an academic to try to understand the behaviours and societal dynamics that were making young women, in particular, so vulnerable to the disease. One factor they studied was how some had multiple partners, which helped HIV to spread. This was “woven into the normal way of life of young women, especially young women who are just starting on their careers . . . just to survive”, she says. Some of these women would have several partners who all contributed in some way to their living expenses.
Dr John Nkengasong, the first director of the Africa Centres for Disease Control and Prevention, says that Moeti’s work was instrumental in ensuring that 1.3 million people had access to life-saving antiretroviral drugs against HIV/Aids by 2005, when only 400,000 had them two years before. The WHO campaign is believed to have prevented between 250,000 and 350,000 deaths.
Much of what Moeti learnt in her battle against the “other African pandemic” has informed her current work. One lesson was the need to implement a testing regime. In mid-February, when the first Covid-19 cases were detected in Egypt, there were only two countries in sub-Saharan Africa that had any infrastructure for diagnosing the virus. Within six weeks, Moeti had galvanised governments to ensure that the majority could test at least one major city with gold-standard PCR tests.
She believes several factors helped countries in Africa weather the storm better than those in Europe and the Americas: early pre-emptive lockdowns, the mostly rural and youthful demographic and the existence of emergency outbreak operations, created to tackle diseases such as Ebola, which were reignited during the early weeks of coronavirus.
However, Africa does have lower testing capacity than most other regions. And many commentators have attributed its relatively smooth run to the fact that its population is very young — the median age is below 20, compared with 43 in Europe.
The virus did puncture Africa’s early defences and had spread to 40 countries by March 23, but numbers stayed low as countries mounted an aggressive effort to ringfence early infections. Aside from the north and south — Morocco, Egypt, Algeria and South Africa — the continent has so far avoided the worst of the pandemic.
There has been serious criticism of the WHO throughout the Covid-19 pandemic — for allegedly being too tightly aligned with China, too weak in its dictates to member states and slow off the mark with some public health interventions. Asked about this, Moeti is measured: “I think member states recognise that the expectations that the world has of the WHO far outstrip the resources that have been made available.”
She acknowledges that the criticisms have been “relentless” and regrets that many have been directed at director-general Tedros Adhanom Ghebreyesus. But has it disturbed her work? “No. It’s made me very determined to make sure that we do our best to navigate this and encourage our team to continue. We are learning. Everybody is learning.”
Moeti says that the lesson she has had to learn, and remind herself of with every epidemic, is the need to make public health interventions community-led, to decentralise control. “It’s only when you get to know the communities that are affected that you can find the most effective way to intervene and, most importantly, the most effective way to support and enable people to take the kinds of actions that they have to take,” she says. In some regions, churches, women’s groups and young people’s networks have galvanised support for responses to Covid-19.
Looking beyond this pandemic, Moeti’s ambition is to build a culture of financial self-sufficiency in African public health. Greater autonomy over finances is “not a very sexy wish”, she admits, but it would “enable us to really negotiate ways of working from a position of authority and strength — which we have”.
Anna Gross is an FT science and environment reporter
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