Analysis Why have so many African leaders died BMJ Glob Health: first published as 10.1136/bmjgh-2021-005587 on 17 May 2021. Downloaded from of COVID-19? 1,2 1 1 1,3 Jean- Benoît Falisse , Robert Macdonald, Thomas Molony, Paul Nugent To cite: Falisse J- B, ABSTRACT Summary box Macdonald R, Molony T, This paper provides evidence that the COVID-19- related et al. Why have so many mortality rate of national government ministers and ► In the 12 months between 6 February 2020 and African leaders died of heads of state has been substantially higher than that of COVID-19?BMJ Global Health 6 February 2021, COVID-19 claimed the lives of people with a similar sex and age profile in the general 2021;6:e005587. doi:10.1136/ at least 24 national ministers and heads of state, population, a trend that is driven by African cases (17 bmjgh-2021-005587 which is well in excess of the reported in- office out of 24 reported deaths worldwide, as of 6 February death rate for such politicians in recent years. 2021). Ministers’ work frequently puts them in close Handling editor Seye Abimbola Seventeen of these deaths are from the African contact with diverse groups, and therefore at higher risk continent (and the count kept growing after 6 ► Additional supplemental of contracting SARS- CoV-2, but this is not specific to February 2021), putting the COVID-19 death rate material is published online only. Africa. This paper discusses five non- mutually exclusive To view, please visit the journal at 1.33% among national ministers and heads hypotheses for the Africa- specific trend, involving online (http:// dx. doi. org/ 10. of states—seven times above estimates of the comorbidity, poorly resourced healthcare and possible 1136/ bmjgh- 2021- 005587). world's average for a demographic profile of sim- restrictions in accessing out- of- country health facilities, ilar sex and age average for the same period. the underreporting of cases, and, later, the disproportionate Received 4 March 2021 impact of the so- called ‘South African’ variant (501Y.V2). ► While comorbidities such as obesity or diabetes can- The paper then turns its attention to the public health Revised 27 April 2021 not be ruled out as a cause of such African speci- Accepted 29 April 2021 and political implications of the trend. While governments ficity, other hypotheses include the lower quality of have measures in place to cope with the sudden loss healthcare and a halt in international medical trans- of top officials, the COVID-19- related deaths have been fers used by African elites as well as, later, the inci- associated with substantial changes in public health dence of the so- called ‘South African’ variant (501Y. policy in cases where the response to the pandemic had V2) of the virus. initially been contested or minimal. Ministerial deaths may ► The trend also invites careful reflection on the also result in a reconfiguration of political leadership, but spread of COVID-19 in countries where data and we do not expect a wave of younger and more gender testing are limited, especially among similar demo- representative replacements. Rather, we speculate that http://gh.bmj.com/ graphic profiles. a disconnect may emerge between the top leadership ► The deaths have an important symbolic value and and the public, with junior ministers filling the void and have been associated with shifts in COVID-19 poli- in so doing putting themselves more at risk of infection. cies in some countries. They are also likely to result Opposition politicians may also be at significant risk of in some reconfiguration of the political space. contracting SARS- CoV-2. on October 2, 2021 by guest. Protected copyright. cases of politicians becoming ill with COVID- 19. However, accurately determining political INTRODUCTION elites’ susceptibility to COVID-19 requires systematic investigation. © Author(s) (or their As the COVID-19 pandemic enters its second employer(s)) 2021. Re- use In this paper, we present evidence that the permitted under CC BY. year, there is an ample and growing body of COVID-19- related mortality rate in national Published by BMJ. evidence that certain demographic factors, governments is substantially higher than that 1Centre of African Studies, such as age and biological sex, affect a of the general population, mostly owing to The University of Edinburgh, person’s susceptibility to the SARS- CoV-2 deaths in African countries. We show that Edinburgh, UK virus.1 2 Socioeconomic factors, including 2Edinburgh Futures Institute, sex and age do not fully explain this trend, The University of Edinburgh, people’s occupations, also impact the likeli- before exploring possible explanations Edinburgh, UK hood that someone is exposed to SARS- CoV-2, and discussing public health and political 3School of History Classics and particularly when jobs are not adaptable to consequences. Archaeology, The University of working from home and involve close contact Edinburgh, Edinburgh, UK with other people.3 Although these jobs are Correspondence to most likely to be held by low- income people, Dr Jean- Benoît Falisse; this description arguably applies to political jb. falisse@ ed. ac. uk elites. There have been several high-profile Falisse J- B, et al. BMJ Global Health 2021;6:e005587. doi:10.1136/bmjgh-2021-005587 1 BMJ Global Health BMJ Glob Health: first published as 10.1136/bmjgh-2021-005587 on 17 May 2021. Downloaded from Figure 1 COVID-19 death rates (as of 15 February 2021). Data sources: ministers and heads of states—deaths: authors’ own compilation/total number of ministers: IPU/UN Women (01 January 2020). General death rate—Sex, Gender and COVID-19 Project (15 January 2021), see text for details. Bars are 95% CI. HOW CAN WE KNOW WHETHER POLITICIANS ARE MORE LIKELY systematically checking the articles containing ‘minister TO DIE OF COVID-19? tested positive’ and ‘COVID-19’ on Factiva. The health and well- being of those in positions of power In January 2020, the Inter-Parliamentar y Union and are typically the subject of much media attention. In the UN (IPU/UN) Women released a count of women in analysis below, we focus on ministers and heads of state. ministerial positions in 190 countries.8 It shows 78% of They represent only a fraction of those in positions of ministers are men and provides the number of people power, but they also constitute a well- defined group that holding ministerial portfolios in each country. In addi- http://gh.bmj.com/ can be counted in a similar fashion across countries. We tion to sex (sex corresponds to gender for most minis- created a list of deaths based on two sources that were each ters), age is a key factor determining susceptibility to systematically verified. First, we looked at lists appearing COVID-19: the WhoGov dataset, which includes infor- in traditional online media—especially Deutsche Welle mation on ministers in 177 countries for the period (Germany),4 The Citizen (Tanzania)5 and Al Jazeera 1966–2016, was the best available source.9 Our focus is (Qatar)6—that mention prominent COVID-19- related on national-level (or federal/union) ministers and heads on October 2, 2021 by guest. Protected copyright. deaths. Second, we sorted through Google News results of states. Data on COVID-19 mortality disaggregated by generated by the keywords ‘minister’, ‘died/dies’ and sex, age and country are available for 54 countries from ‘COVID-19/coronavirus’, in English and French. The the Sex, Gender and COVID-19 Project.10 high visibility of ministers and heads of state means that the list is likely to be comprehensive, but the suppres- sion and politicisation of information on prominent AFRICAN MINISTERS ARE MORE LIKELY TO DIE OF COVID-19 COVID-19 cases remains an issue. Presidents Magufuli We identified 24 deaths that occurred between 6 February of Tanzania and Nkurunziza of Burundi are discussed in 2020 (the first reported COVID-19 death outside Asia) the paper because, while the communiqués announcing and 6 February 2021 (see online supplemental file). We their deaths do not mention COVID-19, many in the focus the statistical analysis on these 12 months. media and civil society have suggested such a (plausible) Using the IPU/UN Women data, this suggests a connection. mortality rate of 0.60% among ministers and heads of state For this reason, and because it is less likely to make the (figure 1). It is significantly different from the general news, listing people who tested positive for COVID-19 is mortality rate for a population similar to the ministers’, more challenging. We focused on Africa and compiled a that is, 60.5 years old and men, which our highest esti- list using data from Jeune Afrique magazine,7 as well as mate puts at 0.17% (using the 56 countries for which we results from manually sorting through Google News and have data on both groups: t(53)=1.780, p=0.087). In 48 2 Falisse J- B, et al. BMJ Global Health 2021;6:e005587. doi:10.1136/bmjgh-2021-005587 BMJ Global Health countries out of 56, 60.5 years is included in a bracket media and the general public. They also tend to travel BMJ Glob Health: first published as 10.1136/bmjgh-2021-005587 on 17 May 2021. Downloaded from that goes up to at least 70 years old and Europe is dispro- a lot, both domestically and, when possible, internation- portionately represented (23 countries). ally. They meet many people from diverse groups, some The WhoGov dataset contains the year of death for of whom, including other politicians, are also in high- some ministers and heads of state. In the most recent risk categories—COVID-19 clusters have been found period (2010–2016), which covers only 101 countries, among the cabinets of Guinea Bissau in March (five posi- an average of 0.24% (SD: 4.894) of them died during a tive cases, including the prime minister),12 South Sudan year when they were in office (which does not necessarily in May 2020 (10 positives)13 and Zimbabwe in January mean they died in office).