A global pandemic needs a global response
What country has not or will not be affected by COVID-19?
Already, the virus has reached 211 states and territories worldwide, with the high-income countries of North America and Europe apparently the worst affected so far (in addition to China). But a more tragic stage of the pandemic may now be emerging in the world’s poorest countries in Africa, Asia and the Pacific Islands, which simply do not have the resources to deal with population health needs.
Numbers of infections and deaths may currently appear limited in these low-and-middle-income countries simply because tests have not been run and relevant data not collected. In any case, the danger is that these countries are now at the beginning of the steeply rising, exponential COVID-19 curve.
This pandemic is just the latest crisis to face the people of these countries. The daily lives of the roughly 700m who still subsist on less than $2/day are already beset by economic insecurity, and the prospect of catastrophic ill health is an ever-present reality. The experience of combating the epidemic in the poorest countries is likely to be very different from that of the higher-income countries.
In many rich countries, like Australia, the focus has been on ‘flattening the curve’, with the primary objective of enabling health systems to cope. The difference in COVID-19 death rates between those countries with a health system able to meet the demands of the pandemic compared to those where the health system is overwhelmed is likely to be very significant, and it is therefore worth considerable economic sacrifice related to social isolation strategies to achieve this objective.
In some high-income countries – the United States among them – neither the health system nor the political leadership appears to have been able to cope with the pandemic, with fatal consequences. Those who have argued that ‘we can’t have the cure be worse than the problem’ may now be exposed as making the situation worse than it could have been – from both economic and health perspectives.
In Africa, it seems the virus is only now beginning to strike, while the 10,000 reported cases (14 April) are likely to be a significant underestimate. But African and other low-income countries face a dual crisis. The shortage of economic resources means that health systems already cannot cope with even the routine set of health problems a population encounters. And the impact of the pandemic – whether in the economic burden associated with implementing a ‘lock-down’ process or in the consequences of wide-spread illness and death – will have further tragic economic consequences.
What can populations in these disadvantaged situations expect? First, there is a present danger that the virus will tear through densely populated urban and residential areas where large households live in close proximity, with generally poorly equipped sanitation services. Where people live cheek by jowl with family members and strangers alike, share toilets and washing facilities, survive on a day-to-day basis often in dirty and insanitary jobs, they cannot protect themselves from infection. Where they are malnourished, suffer from other diseases that we know reduce resistance to the virus, may be immunosuppressed with at best incomplete access to HIV medicines, they will disproportionately experience severe symptoms and death. Almost none of them will see the inside of a functioning Intensive Care Unit.
Meanwhile, efforts to slow COVID-19 transmission rates may also have negative health-system effects, such as diverting needed resources into fighting the pandemic, or, as we have seen, limiting access to HIV drugs in Uganda and South Africa. In the absence of both testing and care facilities, quarantining people with raised temperatures – only some of whom are likely to be COVID-19 affected  – may be a burden these health systems cannot bear.
Secondly, there is the threat of an economic double hit. Efforts to reduce transmission through locking populations down – such as is being attempted in India – will deny people the work they need for survival as well as imposing a series of further hardships. None of the economic stimulus and safety-net funding seeking to counterweight economic down turn in Australia and other such countries will be possible in the lowest income countries.
As well, the impending global recession will hit the long-term prospects of the poorest countries severely. These countries rely on selling commodities and manufactured goods to the rest of the world, and much of the progress made in raising an estimated one billion people out of poverty since 1990 is at risk. Garment factories from Bangladesh to Ethiopia have already been hard hit, prompting a range of measures aiming to stabilise incomes in the immediate crisis but these will be difficult to sustain in a prolonged recession.
Under these conditions, there are lessons to be learned. One is that the role of government is critical, in public health and social security as well as in economics. Now, after decades of implementing policies to privatise services, cut taxation and reduce the size of government, the ability of governments to respond adequately to a pandemic has been eroded. The USA is one example of a country where a privatised health system has failed the challenge. Continuing to propose similar models in poor countries may have been part of the problem and will most likely enhance the vulnerability of those societies.
Ironically, in countries around the world, governments that have for many years been preaching balanced budgets and cuts in social spending have rapidly swung to a new ‘we are all in this together’ message and have rediscovered Keynesian economics. Can we expect a similar reappraisal of the importance of international aid and global solidarity in the face of this most manifestly shared catastrophe? Unfortunately, the decision of the US Executive to cease funding to the World Health Organization is the worst possible sign in the present situation.
The second lesson is the need to take global responsibility for a global pandemic. This makes new demands on the provision of foreign assistance by the world’s richest countries, which has been in decline in recent decades.
Perhaps our best hope lies in the understanding that none of us is safe from the virus until all of us are safe from the virus. As we in high-income countries now get COVID-19 under control, our attention – and our support in resources, expertise and personnel – should be turned to our global neighbours in need. We have a window of opportunity right now to press for foreign policy and development assistance based on the principles of solidarity rather than self-interest.
This pandemic has revealed long standing structural and political flaws in the current global system. It also provides the crucial opportunity to change direction, towards policies and processes that encompass all those in need, across the globe. This is the future we are now inevitably facing.
15 April 2020.
Professor Barbara McPake, Director, The Nossal Institute for Global Health
Professor Peter Annear, Senior Technical Consultant, The Nossal Institute for Global Health
Associate Professor Linda Rae Bennett, Head of Education and Learning, The Nossal Institute for Global Health
Professor Ajay Mahal, Health Economics and Health Systems, The Nossal Institute for Global Health