“’I’m…. involved in the Eastern Congo… and am conscious of the looming catastrophe if the Corona virus would bring about respiratory complications….In the referral hospital in Beni, already disorganized by the ending [the] Ebola epidemic, there are 2 oxygen concentrators, and regular power cuts. You can imagine….” – Dr. Réginald Moreels, Humanitarian surgeon and former Minister of International Cooperation, Belgium

The Kibera slum in Nairobi, Kenya, during COVID-19. Physical (social) distancing will not be easy

The Kibera slum in Nairobi, Kenya, during COVID-19. Physical (social) distancing will not be easy. Image courtesy of Tyler Hicks/New York Times.

As an American, a native New Yorker, I know that it is hard not to focus on the terrible toll that COVID-19 is taking here in the United States. I feel it every day. But just as we will only we get through this without further avoidable death in the United States by working together, from each of us adhering to stay-at-home directives to states sharing ventilators, so must we cooperate – and focus attention and resources – globally.

For all the inexcusable delays, missteps, lack of federal action, and other problems with the U.S. response, we still have many advantages. We have the economic wherewithal, even if not as wisely applied as it might be, to inject trillions of dollars into the economy, including sending money directly to people suffering most economically. However harmful our lack of medical supplies and equipment, and health personnel, our supplies and numbers of health workers are enviable compared to numerous less wealthy countries, especially in much of Africa.  Consider that the Central African Republic has 3 ventilators, and Africa’s largest country, Nigeria, is believed to have fewer than 500. And they are not alone. The United States has more than 9 times (p. 112) the number of doctors per 10,000 population and nearly 8 times the number of nurses and midwives per 10,000 population as the WHO African Region average.

COVID-19 was slower to come to and erupt in poorer parts of the world, including Africa, Latin America, and parts of Asia. Less travel with other parts of the world that were experiencing higher caseloads, in particular China (most cases in Africa came from Europe) may have helped. Lack of detection may mean that COVID-19 may in fact have then greater hold earlier than reported levels of infection indicated.

Many less wealthy countries, knowing that their health systems could not handle the type of surges of patients that were overwhelming even European nations, and then the United States, and learning from their experiences, implemented “lockdowns” much earlier relative to the number of (known) infections than the United States and many European countries. Perhaps this will help limit the spread –  or only delay disaster. Younger populations, particularly in Africa, should mitigate fatality rates.

Yet far weaker and less-resourced health systems, lack of universal health coverage, crowded slums where social distancing is all but impossible and people may not have access to sufficient hygiene, and large portions of population who cannot telework and may have no choice to work if they are to eat, all threaten disaster.

Of as much concern as the direct health consequences of the coronavirus itself are its knock-on effects. As already under-capacitated health systems direct resources to COVID-19 and away from other health priorities, as physical distancing may limit other health outreach efforts, and if health workers become infected and die, deaths from other diseases could soar. During the West African Ebola epidemic, increased deaths from AIDS, tuberculosis, and malaria alone may have killed nearly as many people as Ebola itself. Meanwhile, the economic consequences of lockdowns – the very measures needed to mitigate the health risks – may themselves be deadly, especially by increasing food insecurity (and, like here, domestic violence).

While systematic vulnerabilities cannot be solved overnight, nor in the coming weeks, urgent action could save countless lives. Accordingly, well over 100 organizations and health leaders from around the world are calling for the level of global solidarity that this global pandemic demands.  In a letter (PDF, HTML) to the heads of state and government of the G20 nations, signers urge action across six areas:

  1. Funding: From funding the UN and WHO COVID-19 appeals to well over $100 billion to provide an economic lifeline and shore up health systems, the G20, along with other funders, must vastly scale up their assistance. Consider this: the U.S. $2.2 trillion COVID-19 stimulus package enacted contained all of $1.15 billion – not even 0.05% of the total – for international programs.
  2. Debt relief: Countries need to immediately inject money into their economies, support their health workers, and purchase medical supplies and equipment. Now is not the time for serving debts to international creditors. The letter calls for suspending debt service payments, along with significant, longer-term debt relief to enable countries to focus their resources on recovery. (Update: At a G20 meeting of finance ministers and central bank governors on April 15, the G20 agreed to “a time-bound suspension of debt service payments [for official bilateral creditors] for the poorest countries that request forbearance.”) 
  3. Equitable distribution of medical equipment and supplies: In March, G20 committed to “expand manufacturing capacity to meet the increasing needs for medical supplies and ensure these are made widely available, at an affordable price, on an equitable basis, where they are most needed and as quickly as possible.” Today’s reality – where scarce supplies, like personal protective equipment and ventilators, go to the highest bidder, with poorer countries losing out – betrays this commitment. G20 countries and other countries, working with WHO, should agree on mechanisms, such as guidelines for the global distribution of medical supplies and equipment based on need, or vastly scaled up donations, to meet this promise. And countries that are past their peak should share any excess capacity with countries that cannot meet their needs.
  4. Equitable distribution of therapies and medicines: The global scramble for therapies and vaccines, once these are ready, must not echo what we are seeing now with medical supplies and equipment. G20 countries, working with WHO and other countries, must come to an agreement on how therapies and vaccines will be shared, again equitably and based on need.
  5. Remove and reform export controls, sanctions, and travel restrictions that are undermining the global COVID-19 response: Export bans, sweeping sanctions regimes, and travel restrictions limit the ability of less wealthy countries to access medical supplies and equipment, and impede the international travel of health and humanitarian workers. These trade and travel regimes should be reformed to enable equitable, needs-based distribution and to ensure that people responding to COVID-19 can get where they are going without delay. (To its credit, the European Commission is now proposing that the European Union narrow its export ban of personal protective equipment to masks only, and to allow masks to be exported as a form of humanitarian aid.)
  6. Protect people who lack protection from their governments and other marginalized populations: The crowded conditions of and often poor hygiene available in camps of refugees, asylum seekers, and internally displaced people create conditions ripe for disaster, as do these populations’ limited access to health care. All humanitarian appeals, traditionally underfunded, must receive full funding, protecting the health and safety of these most vulnerable of populations. And countries must ensure that not only their citizens, but also all non-citizen migrants and immigrants, have access to free COVID-19-related testing, care, and treatment.

Further, the letter urges, G20 countries must take every measure necessary to protect their own marginalized and vulnerable populations – people who are homeless, elderly, disabled, incarcerated, detained, and low-income, among others.

The question now: Will the G20 countries create an action plan for an equitable, rights-based response, and will individual G20 countries step up their global responses in line with the points in this letter, or will they allow systematic domestic and global inequalities to continue to define the unfolding history of this pandemic?