As countries with greater political stability and more sophisticated health systems fight all-out battles against the novel coronavirus, all eyes now turn to countries in the global south in Africa, Latin America, and Southeast Asia. Most countries in these regions have yet to experience a significant wave of coronavirus cases and deaths, but are following a similar trajectory.
The term “global south”—used to capture differences in economics and development—now captures the divide in investment in healthcare systems, and the probability that these systems can contain the spread of the COVID-19 disease. In late January, when the World Health Organization (WHO) declared that COVID-19 was a public health emergency of international concern, its director, Tedros Ghebreyesus, emphasized that a major worry was countries with weaker health systems, like those in the global south.
In past disease outbreaks, the approach of wealthier countries has been to invest human and financial resources in poorer countries to prevent the need to fight the virus on their own soil. However, COVID-19 has flipped the equation. As wealthy nations in Europe and North America battle to protect their own populations, they are realizing the public health effects of nationalistic ideologies and the impact of cuts to public programs that have left them unprepared to adequately respond to COVID-19.
Poorer countries that have struggled to build their health systems, particularly as multilateralism has been challenged, are being faced with a new reality where they must prepare for, fight, and recover from COVID-19 on their own.
Healthcare Systems and Challenges
Most healthcare systems of countries in the global south serve populations under constant health and political crises. One example is South Africa, which is home to the highest prevalence of HIV. Another is Nigeria, which is currently battling the largest recorded outbreak of Lassa Fever. There is also Venezuela, which is in the middle of an unprecedented economic and political collapse. And while not often labeled as part of the global south, many places in the Middle East—such as Yemen, Syria, Palestine, and Libya—have more acute challenges like daily conflict, large vulnerable populations, famine, or other deadly diseases that could exacerbate the effects of the novel coronavirus.
Another more fundamental issue is the availability of basic personal protective and life-saving equipment. This equipment is usually out of reach of the global south; even more so when wealthier countries are prioritizing their own populations. The fact is that whatever equipment global south countries can get now will still be critically inadequate to serve their population’s needs. One hopes that the infrastructure and experience from other outbreak responses such as Ebola in West and Central Africa, Zika in South America, and Nipah in India will contribute to better preparedness for health security in the global south, but the question of whether it will be enough still remains.
The Impact of Multilateral Efforts on the Global South
The WHO and powerful countries like the United States have often led multilateral efforts in global health security, which has produced frameworks like the International Health Regulations (IHR) to guide all countries in case of public health emergencies. The WHO’s Joint External Evaluation exercise has guided more than 100 country assessments of health system performance and compliance under IHR. Similarly, the Global Health Security Index (GHSI) assesses the biosecurity readiness of 195 countries. Both tools result in high-income countries such as the United Kingdom scoring much higher than low-income countries, on average by more than ten points (on a 100-point scale) in the GHSI.
IHR once served as a global quasi-legal tool to reduce the impact of outbreaks on local and global economies. Early moves from some governments in response to the coronavirus outbreak in China saw those agreements quickly tossed aside, and a result of significant economic damage. In addition to the predicted recession, many global south countries and companies are experiencing a different backlash for trying to abide by global agreements. For example, Ethiopian Airlines was one of the last airlines to suspend flights to China—receiving high levels of criticism from Ethiopians. Similarly, many African and Latin American countries that have tried to enact evidence-based policies now find themselves forced to close their border and enact travel bans, including several countries, such as Uganda and Niger, that restricted travel before they had any confirmed cases. The reality of porous land borders in less-secured countries makes such moves far less effective than in Western countries—evidenced by an imported case of COVID-19 in Nigeria via a land border.
Finally, due to the glaring absence of leadership and global coordination, the pandemic response funding once promised from multilateral efforts has been disappointingly low. The WHO’s traditional efforts to raise funds for the response to coronavirus have produced dismal results, but have birthed innovative approaches such as the direct, crowd-funded Solidarity Response Fund. Perhaps most disappointing is the failure of global pandemic financial instruments that were developed for such a time as this, namely, the World Bank’s Pandemic Bond and the WHO’s Emergency Fund, which have not yet been paid out.
Post-Ebola and Post-SARS Institutions and Networks Provide Hope
While a shortage of intensive care unit beds, isolation spaces, and ventilators paints a dire picture for the clinical response to COVID-19 in global south countries, the existence of stronger regional and national institutions and higher sensitization within populations give many resource-constrained countries hope that the virus can be contained.
In Africa, one post-Ebola reform was the creation of the Africa Centres for Disease Control and Prevention (Africa CDC), established in 2017, which provides leadership as the regional institution with the mandate to coordinate and strengthen all African national public health institutions (NPHIs). Africa CDC is an organ of the African Union (AU) and was developed through collaboration between the AU and the US government, as well as other partners like the Chinese government, World Bank, and the Gates Foundation. In the current outbreak, Africa CDC has provided training to personnel in 43 African laboratories and is supporting their ability to test for the novel coronavirus.
In tandem with the establishment of Africa CDC, NPHIs such as Nigeria’s Centre for Disease Control and the Ethiopian Public Health Institute have recruited and trained hundreds of field epidemiologists, lab technicians, infection prevention and control specialists, and other frontline workers that will be critical in fighting COVID-19, especially in light of Africa’s overall critical shortage of health care workers. And most critically during an emergency, these institutions have built trust with their citizens—a currency essential for communities to abide by public advisories, which may be difficult to enforce by law.
Similarly, the Association of Southeast Asian Nations (ASEAN) was strengthened and leveraged in 2003 to combat the outbreak of severe acute respiratory syndrome (SARS) successfully. ASEAN adopted a joint plan of action to harmonize interventions such as temperature screenings and health cards, and set up a network of institutions to share experiences and findings. Critically, ASEAN worked closely with China to track cases and share information. They also worked closely with institutions such as the International Air Transport Association (IATA) to implement agreed upon guidelines for reducing transmission at airports and in aircrafts. Then, wealthier ASEAN countries such as Singapore, supported those with weaker economies and health systems (e.g., Vietnam and Cambodia). The hope is that the same will take place during the coronavirus pandemic.
The Need for Multilateralism and New Partnerships
While multilateralism continues to be challenged, it is still needed—not just by poorer countries, but also by middle- and high-income countries. In the past, the benefits of multilateralism appeared unidirectional from global north to south, but that is far from the truth. There is growing evidence of technical expertise, experience sharing, and mutual benefits from close collaborations and “twining” of NPHIs from all countries. In fact, many of the premier scientists from the West were taught by less-known counterparts in the global south. The story of Congolese doctor Jean-Jacque Muyembe and his important role in the discovery of Ebola is one oft-cited example.
During this pandemic, the world can learn from the experience of Liberia and Sierra Leone in carrying out quarantines and school closures for extended period of times. The approach of countries like South Korea in contact tracing and app-based alerts are also critical. Singapore, Hong Kong, and Taiwan can share strategies learned from SARS and now COVID-19 in targeted responses that aggressively combat outbreaks using democratic and evidence-based interventions. And China with its progressive Africa business-strategy can donate, not lend the resources and equipment needed to support the impending surge of severe COVID-19 cases that the continent will have to care for.
Going forward, the global community must use multilateralism as a tool to ensure the equitable distribution of novel treatments and vaccines once they become available. It will be important to form new alliances that are based on openness between countries and which work to eliminate stigma, discrimination, and xenophobia in the aftermath of this pandemic. Positive lessons from effective public health responses and democratic interventions should be amplified. Responses to public health emergencies must be according to local realities but work to achieve global aim. To fight this and future epidemics, all countries must use approaches which emphasize that we are all in this together, whether we like it or not.
Ngozi Erondu is an Infectious Disease Epidemiologist, Associate Fellow in the Global Health Programme, Chatham House, a 2017 Johns Hopkins Emerging Leader in Biosecurity, and a 2017 Aspen New Voices Fellow.
Emmanuel Agogo is a Primary Care Physician with a background in Tropical Medicine and Infectious Disease and was a 2019 Johns Hopkins Emerging Leader in Biosecurity.