The Impending Global Health Challenges of COVID-19: What We Can Do
By Michael VanRooyen, MD, MPH
While the COVID-19 pandemic has already disrupted political, financial and medical institutions globally, the most severe impact of the virus has not yet been felt. With over 168 million people already in need of humanitarian assistance globally, the escalation of the pandemic in humanitarian settings is an urgent threat that must be rapidly addressed.
As with other pandemics, COVID-19 will disproportionately affect the most vulnerable patients and populations. As we have seen already in this outbreak, elderly and immunocompromised patients experience significant risks, overburdening even advanced health systems. In humanitarian settings, the compounding vulnerabilities of weak health systems and the dynamics of displacement will dramatically enhance the destructive reach of this novel coronavirus.
The World Bank has pledged $12 billion in coronavirus funding, but only $3.3 billion will take the form of grants for lower-income countries. Other international organizations have announced measures designed to tackle the virus, but currently unclear is the degree to which this funding will reach on-the-ground programming serving vulnerable groups. Humanitarian organizations are mobilizing their own resources to serve displaced populations in an attempt to contain the rapidly spreading coronavirus, but without sufficient financial resources and widespread political commitment, this challenging work of containing the pandemic in humanitarian settings could become impossible.
While media attention remains narrowly focused on the impact of COVID-19 in the US and Europe, the international community must address the need to manage this new pandemic within ongoing humanitarian emergencies.
Broken healthcare systems and vulnerable populations
Areas afflicted by conflict and crisis often suffer from broken or degraded health systems. Countries experiencing long-term humanitarian emergencies, such as the Democratic Republic of the Congo, Syria and Yemen are particularly vulnerable to the devastating effects COVID-19, due to their diminished capacity to detect, track, and manage the pandemic.
Even in highly-resourced healthcare systems of the US and Europe, the lack of available testing has bedeviled providers, increased patient risk and prevented the formation of an accurate epidemiologic profile. This means that numbers of exposed or positive cases, as well as accurate mortality statistics, are not known. The severe lack of critical medical resources in humanitarian settings means providers and public health officials will be operating blindly. Border closures, quarantines, trade disruptions and market volatility will continue to disrupt global supply chains, further restricting access to sufficient supplies of medical necessities, personal protective equipment, food, humanitarian assistance and other critical needs.
Given the rate of expansion of the epidemic, refugee settlements and dense urban settings are at particularly high risk and will require vigilant approaches to case identification and treatment. With over 71 million people currently forcibly displaced, these populations face the imminent threat of an epidemic that could claim thousands. Though the confirmed number of COVID cases in displaced communities is currently small, this is almost certainly due to a lack of testing and recognition of the virus. Iraq recently reported its first case in an IDP camp in Nineveh, and COVID has already been documented in several countries with ongoing humanitarian emergencies, including Somalia, Afghanistan, Nigeria, Sudan and Venezuela. Cases, both confirmed and unrecognized, will continue to spread without urgent action.
The logistics of diagnosing and treating COVID-19 in refugee settlements, particularly densely populated displacement camps in Bangladesh, Syria and Yemen, will become major challenge. In these densely populated areas, the risks of rapid spread loom large and there are very few resources to control or treat infections. Health and sanitations systems in these settings are already stretched, dealing with other diseases and epidemics, where the underlying health status of both children and adults are already compromised. The infection mitigation strategies currently being promoted, such as social distancing, are functionally impossible in most settlements and dense urban settings. These pervasive conditions set the perfect stage for a rapid and deadly outbreak of COVID-19.
Preparing for COVID-19 in humanitarian programming
UN agencies and NGOs working with vulnerable populations must rapidly scale-up their efforts to prepare for COVID-19 and must develop context-specific strategies that address the specific challenges of the community being served. National action plans in host countries must address refugees, migrants, IDPs and other high-risk groups.
Prioritizing foundational public health practices are a good first step, including promoting and facilitating hand washing, pandemic monitoring and case reporting. Basic personal protective equipment (PPE) such as masks, will be essential for health care workers and those caring for ill patients, despite current global shortages. These preliminary measures will help to “flatten the curve” in humanitarian settings, where actions such as social distancing are difficult and curative medical services are limited at best.
The same health infrastructure that was built to contend with recent Ebola outbreaks may prove useful for confronting COVID. Uganda, for example, is using the same training resources, mechanisms and PPE procedures as those developed for Ebola. However, the method of transmission and treatment options are very different for the two diseases, and most affected communities are not trained in managing Ebola. Enhanced methods for public health education and community-based interventions will be most helpful in alerting vulnerable groups to this new threat.
Up-scaling humanitarian operations
Many international organizations are limiting travel and closing down central operations, while attempting to maintain local operations for recipient groups. Needless to say, it will be critical to maintain public health, medical and social services to vulnerable communities despite travel restrictions. Humanitarian funding may be further redirected by donors and several donor states are considering redirecting funding intended for humanitarian response toward domestic spending on internal health responses. However, it is critical that countries maintain and increase their voluntary contributions for humanitarian organizations such as WFP, UNHCR, UNOCHA, FAO and WHO, which provide life-saving resources to the world’s most vulnerable populations, and work to build systems that maintain healthier populations in the long run. This pandemic will test our ability as a humanitarian enterprise to work tirelessly and creatively to protect our staff and assure the health of those we serve, while advocating for the rights of those most in need of protection. The humanitarian implications of COVID can no longer remain an afterthought; effectively meeting this crisis with critical resources and political commitment is a public health imperative.
Michael VanRooyen, MD, MPH is the Director of the Harvard Humanitarian Initiative and Chair of the Department of Emergency Medicine at Brigham and Women’s Hospital.