Coronavirus Will Disproportionately Affect the Poor & Vulnerable
COVID-19 is spreading like a wave, but for low-income countries it will be a tsunami
It wasn’t long ago that the entire world was looking at West Africa and the Ebola epidemic which ran rampant through Sierra Leone, Libera, and Guinea. In the end, over 28,000 people contracted Ebola and more than 11,000 of them died. I responded to the Ebola epidemic as a frontline clinician and saw first-hand how West Africa was wholly unprepared for Ebola. Ultimately, that epidemic took tens of thousands of health professionals and billions of dollars to contain.
Today we’re dealing with a new epidemic, verging on pandemic. On February 25th of this year, the Centers for Disease Control and Prevention (CDC) announced that COVID-19 is likely to spread within the United States. Nancy Messonnier, Director of the National Center for Immunization and Respiratory Diseases, said, “Ultimately, we expect we will see community spread in the United States. It’s not so much of a question of if this will happen in this country anymore, but a question of when this will happen.” This announcement comes on the heels of the virus’ rapid spread not only throughout China but, as of February 28, now reaching more than 53 countries, with over 83,000 confirmed cases including in Brazil, Egypt, and Nigeria. The countries that have been hardest hit by COVID-19 have robust public health systems and widespread availability of advanced care, including intensive care units with the equipment and expertise to manage critically ill patients requiring intubation. But, given the rate of spread of this emerging pandemic, what will happen when the virus takes hold in limited-resource settings, further straining health systems that are already weak and underfunded?
In Wuhan, China, where the epidemic started, the mortality rate seems to be hovering between 2 and 4 percent. Most cases have been deemed mild — similar to the common cold — but in one case series of 138 patients, 26% had severe complications and required intensive care. Although the degree of transmissibility is still being determined, this novel virus appears to be much more transmissible than previous coronaviruses, including MERS and SARS. But, COVID-19 will soon hit countries that don’t have robust health systems; it is inevitable. In these settings, care can be difficult to obtain, diagnosis can be challenging, and high-level tertiary care is vanishingly rare. We should expect that in low-resource conditions, COVID-19 will spread faster, with higher acuity, and lead to worse outcomes than we have seen in high-resource settings to date.
After what the international community learned in the 2014–16 Ebola response, we should be quite concerned about COVID-19’s spread to low-resource settings. Recognizing the many differences between Ebola and COVID-19, here are six considerations we would do well to remember for this epidemic response.
The transmission rate of Ebola was relatively low; for every person that contracted Ebola they would, on average, spread it to two other people. Ebola is transmitted via bodily secretions, thus close contact with someone infected is required for transmission. By contrast, COVID-19 is airborne, rendering it much easier to transmit. To complicate matters further, there is emerging evidence that some people who haven’t demonstrated symptoms of COVID-19 (fever, cough) are still able to spread the virus. Thus, although challenging, Ebola is containable if you are able to both identify and isolate those who have contracted the virus and everyone with whom those people came in contact.
How do you contain a virus that is transmitted in the air and for which people who haven’t yet developed symptoms can spread it to others? It’s nearly impossible, which is why even China’s herculean efforts to quarantine the entire city of Wuhan only slowed the spread of the virus.
There is already evidence that more than 1700 health care workers in China were infected with COVID-19, including fatal cases, notably the whistleblower Dr. Li Wenliang. During the epidemic of SARS and MERS, the majority of cases were associated with spread within hospitals and led to a significant number of hospital staff who fell ill. Infection control is critically important in hospitals and healthcare settings, especially with airborne infections, to protect both staff and patients. At Brigham and Women’s Hospital in Boston, where I practice medicine, we have specialized ‘negative pressure’ rooms for patients with airborne diseases — rooms with ventilation which prevent air that may have airborne pathogens from spreading outside the room.
We also have N-95 masks and personal protective equipment (PPE), both of which are critical to preventing nosocomial spread, or spread of a virus inside the hospital to staff and/or other patients. With PPE already in short supply globally, and the lack of effective ventilation systems for infection control, the risk of infection spreading within hospitals in low-resource settings is incredibly high. During the Ebola epidemic, large swaths of healthcare workers fell ill with the virus: in Guinea, health care workers were 42 times more likely to contract Ebola than non-healthcare workers. The ability to keep patients and staff safe, free from contracting and spreading infection within healthcare settings, is going to be a significant challenge in this epidemic, especially in light of the airborne spread of the disease.
Currently COVID-19 is diagnosed with reverse transcriptase polymerase chain reaction (RT-PCR), a test that can only be performed in specialized laboratories. PCR has become a common technique in laboratories across the world, but it remains out of reach for most labs in sub-Saharan Africa. Many medical laboratories in these settings are under-developed, under-funded and struggle with both systematic and infrastructure capacity weaknesses, with few quality assurance standards. An evaluation conducted in 2013 of accredited laboratories in the region found that 37 of 49 countries did not meet internationally recognized quality standards; insufficient staff, unaffordability of laboratory tests, low qualification levels, and limited career opportunities all add to the problem.
The ability to rapidly diagnose COVID-19 is essential. In epidemics and pandemics, diagnostic tests that are readily available and widely disseminated are key to treatment and prevention efforts. According to Dr. Tedros Adhanom Ghebreyesus, WHO Director-General, forty-one African countries can now test for potential COVID-19 cases. Earlier this month, only two countries — South Africa and Senegal — had this capacity, and samples from early suspected cases in Ethiopia and Kenya had to be sent across the continent to be tested, drastically decreasing response times. While this increased capacity represents progress, the reality of the laboratory landscape in Africa remains cause for concern, and will undoubtedly further complicate already-difficult response efforts.
There is no specific antiviral treatment or curative treatment available for COVID-19. Clinicians must instead provide care through supportive, rather than curative therapies, meaning they treat symptoms of the disease and prevent and manage complications. Vital to this supportive care is the administration of medical oxygen, especially for moderate to severe infections. However, in low-income countries, oxygen isn’t reliably available; oxygen cylinders, oxygen concentrators and larger oxygen plants are all sporadic. This scarcity is largely driven by the cost of oxygen, maintenance of oxygen-delivery machines such as oxygen concentrators, poor transportation infrastructure, and lack of reliable electricity. In a study conducted at 231 health facilities in 12 African countries, researchers found that only 29 percent of surveyed facilities had regular access to at least one oxygen cylinder and only 24 percent had access to a functioning oxygen concentrator — not nearly enough to handle everyday oxygen requirements, which would be even more strained in a COVID-19 outbreak.
Research is underway for an antiviral agent for COVID-19, and there has been some enthusiasm about several antiviral agents currently being tested in the US. But even with an effective antiviral agent, the ability to provide supportive care, as well as manage complications of the disease, are essential to the ability to keep morbidity and mortality low.
While mortality for COVID-19 is currently estimated to be 2 and 4 percent, those numbers are unlikely to reflect the estimated deaths in low-resource settings. Again, Ebola may prove to be illustrative here. The case fatality rate (CFR) for Ebola in West Africa varied dramatically during the epidemic. Some Ebola Treatment Centers reported CFRs of 25 percent while others placed it at 90 percent. What accounts for that incredible variation in CFR? Simply put, the availability and robustness of supportive care and in some cases the ability to provide critical care. Ebola Treatment Centers that were able to treat patients early in the onset of their disease and provide effective supportive care (intravenous fluids, antibiotics, and treat comorbid illness) were able to attain lower CFRs. Similarly, almost every case of Ebola that was transferred to Europe or the United States survived, in large part because they had access to critical care. Thus, a clear line can be drawn between availability of care — in some cases intensive care for severe complications — and mortality, especially in epidemics with virulent communicable diseases like Ebola and COVID-19.
Although the clinical presentation of COVID-19 can be as mild as an upper respiratory tract infection, the available data suggests the complication rate may be as high as 26 percent, which will likely increase the mortality seen in resource-constrained settings. The lack of critical care — specialized care for patients whose conditions are life-threatening and require comprehensive care and constant monitoring — in low income countries is tied to both the lack of infrastructure, as well as the dearth of specialists in these settings (namely, physicians and nurses trained to provide care to critically ill patients). Critical care requires a combination of intensive monitoring, specialized equipment and highly trained clinicians, most of which are lacking in low-income countries settings.
In low- and middle-income countries, there are only between 0.1 and 2.5 intensive care unit beds per 100,000 people, a small fraction of the 33.6 beds per 100,000 available in the US. Haiti, for example, has only 15 intensive care unit (ICU) beds for a country of 10 million. What will happen when up to 26 percent of the tens of thousands of Haitians who will fall ill with COVID-19 need intensive care? Even in Wuhan, a city of nearly 8 million people, the Chinese government rushed to add 2600 hospital beds in record time to treat those affected with COVID-19, many of which were ICU beds.
In the effort to respond to epidemics, the international community often overlooks the consequences for basic healthcare provision in already-fragile health systems. For countries with weak health systems forced to grapple with epidemic illness, the diversion of limited resources away from basic health services can be more severe and longer-lasting than the illness itself. A study from 2016 estimates that during the Ebola epidemic, there was a full 50 percent reduction in access to healthcare services, which dramatically exacerbated malaria, HIV/AIDS, and tuberculosis mortality rates. In Liberia, childhood immunizations were significantly reduced, primary health care came to a virtual halt, and cases of malaria nearly increased by 50 percent. Pregnant women also bore the brunt of Ebola, with facility-based deliveries and overall use of maternal health services decreasing by more than 80 percent in some areas.
There have been improvements in diagnostics, therapeutics, surveillance, and national and international coordination since the Ebola outbreak, but the stark reality is that many resource-constrained countries remain as vulnerable as they were prior to Ebola. History has demonstrated that disease and illness almost always disproportionately affect the poor, and COVID-19 is primed to do the same. What should low-resource countries do in the face of this tsunami at their door?
While “health systems strengthening” is an attractive goal, much of the momentum and lessons learned from Ebola was hamstrung by lack of funding or took a backseat to other pressing priorities in these already overextended and weak public health systems. Even as the US increases its own epidemic prevention and response measures, we must confront the reality of COVID-19 globally, and the threat it poses to communities more vulnerable than our own. Though little time remains before the storm surge of illness hits, the international community can help work in solidarity with low-income countries to stem the tide of this new virus, which will certainly make a preferential option for the poor and marginalized in its virulence, morbidity, and mortality.
