AS Africa emerges from its second wave of COVID-19, one thing is clear: having officially clocked up more than 3,8 million cases and more than 100 000 deaths, it hasn’t been spared. But the death toll is still lower than experts predicted when the first cases were reported in Egypt just over a year ago. The relative youth of African populations compared with those in the global north — while a major contributing factor — may not entirely explain the discrepancy. So what is really going on in Africa, and what does that continent’s experience of COVID-19 teach us about the disease and ourselves? “If anyone had told me one year ago that we would have 100 000 deaths from a new infection by now, I would not have believed them,” says John Nkengasong, the Cameroonian virologist, who directs the Africa Centres for Disease Control and Prevention (CDC) in Addis Ababa, Ethiopia. Incidentally, he deplores the shocking normalisation of death that this pandemic has driven: “One hundred thousand deaths is a lot of deaths,” he says. It’s also an underestimate. Under-reporting is happening all over the world, but the fragility of many African health systems and relative inaccessibility of tests — of which more than 35 million have been carried out since the pandemic began, in a population of 1,2 billion — are exacerbating the problem there. A study soon to be published in the British Medical Journal, which involved post-mortem polymerase chain reaction testing of 364 bodies at a university hospital morgue in the Zambian capital, Lusaka, showed that one in five were infected with the virus. Most had died before reaching hospital, without being tested. Christine Jamet, the Geneva-based director of operations for the medical charity Médecins Sans Frontières (MSF), says that it will take time to establish the full impact of the African epidemics, but the idea that the continent has had a mild brush with COVID-19 is wrong. Many African countries put measures in place at the same time as Europe last spring, before they had reported any cases — and flattened the initial curve far more effectively as a result —but they have been hit hard by the second wave. In the current hotspots, which include Eswatini, Malawi and Mozambique, “the hospitals are overrun,” Jamet says. “We have put up tents beside them to care for patients who wouldn’t otherwise have beds.” The situation has been aggravated by a shortage of oxygen — one reason, Nkengasong says, why the average case fatality rate (CFR) across Africa has recently overtaken the global average of 2,2%. It now stands at 2,6%. The CFR is itself a blunt instrument, since a “case” is harder to define — and with regard to managing the pandemic, less informative — than an infection, whether that infection produces symptoms or not. But testing is not good enough across Africa for the more useful infection fatality rate to be calculated. And yet, even accounting for under-reporting, Nkengasong believes that death is visible enough in African communities that he can say with confidence that overall, the d