About two months ago, when Covid-19 was still a somewhat distant problem in the United States, I caught sight of a poster in a remote airport in the Peruvian Amazon warning about the coronavirus.
At the time I was leading a global health team from Dartmouth College working with Peru’s National Telehealth Network to extend its telehealth program to remote rural communities with limited health infrastructure and health care workers. The team has since turned its attention to supporting Peru and partners in other low- and middle-income countries confront the pandemic that has swamped the world’s strongest health systems.
As the U.S. grapples with the challenges resulting from the gross failures of leadership — shortages of ventilators that could have been averted by earlier countermeasures, lack of adequate personal protective equipment, resistance of the population (and some leaders) to public health measures like social distancing — I am reminded of the need to look to the expertise and strategies of other countries.
In nearly 20 years of working in many of the world’s poorest countries, I’ve seen enormous progress in addressing infectious disease and other global health priorities. Yet, I know that rapidly improving health systems in Peru and other low- and middle-income countries are wholly unequipped to respond to this epidemic.
If the goal is to flatten the curve to levels that health systems can accommodate, the U.S. could do that with its more than 34 ICU beds per 100,000 people, but there is no level to which the curve can be flattened in Haiti, which has just 68 ventilators for a more than 11 million people, or Uganda, which has just one ICU bed per 1 million people. Only 1.5% of countries in sub-Saharan Africa have the capacity to treat sepsis, just 43% have a stable supply of oxygen for their existing patient loads, and only two — Senegal and South Africa — had the ability to do PCR testing for Covid-19 at the outset of the pandemic.
It’s clear that we need to support low and middle-income countries in preparing for this looming threat. At the same time we also need to learn from the early leadership of Peru and other countries, including Rwanda and Nigeria, in addressing this epidemic. We can also learn from the vast gains many of the world’s poorest countries have made in reducing deaths from epidemic disease.
Most notable is the extraordinary success in stemming the tide of the HIV pandemic, which only 20 years ago threatened to decimate sub-Saharan Africa. Rates of treatment coverage in many parts of sub-Saharan Africa now outpace those in wealthier regions of the world. Today, thanks to lifesaving antiretroviral therapy, more than 24 million people with HIV are alive, the vast majority of them in sub-Saharan Africa and other low- and middle-income countries.
These successes offer four important lessons:
First, we can learn from strategies central to the rapid expansion of HIV treatment in sub-Saharan Africa as we redeploy scarce health systems resources to treat a surge of Covid-19 patients and sustain basic health services. Task shifting, or transferring responsibilities to lower levels of providers, including community health workers, was essential to overcoming severe workforce shortages and geographical barriers to care.
Second, the early failure of many countries to address rising rates of HIV marginalized populations — sex workers, users of injected drugs, the LGBTQ communities, and others — until the epidemic spilled over into the general population reminds us of the danger of disease control strategies that replicate patterns of discrimination or social prejudice. Protecting the most vulnerable communities and ensuring equitable access to treatment for all, including undocumented and incarcerated individuals, will be essential to stemming the spread of Covid-19.
Third, community-led efforts during the 2014-2016 Ebola epidemic in West Africa teaches us about the critical role of local leadership in overcoming resistance to social distancing and other public health measures. Local leaders in Liberia and Sierra Leone organized neighborhood campaigns to identify and isolate cases of Ebola in dense urban slums and worked with religious leaders to stop body washing, a burial practice associated with widespread disease spread.
Fourth, and most importantly, biomedical advances or technology did not alone propel the gains we see globally. Rather, it was a global movement for equity in access to them. Scientists, activists, civil servants, patients, health care providers, and communities came together to battle for access to drugs, forcing systems to deliver them. It is critical that we begin a similar movement to ensure equitable access to personal protective equipment, diagnostics, and other essential supplies, as well as to treatments and vaccines when they become available.
We cannot, of course, simply let poor countries become a textbook for how to correct the faltering pandemic response in the U.S. Supporting them, as well as the World Health Organization and other global public health institutions, must be central to our strategy to ending this pandemic. This is not merely an act of solidarity or global justice it is also good public health strategy.
Global indifference to the 2014-2016 Ebola epidemic while it ravaged three of the world’s most fragile countries in West Africa resulted in its spread to the U.S. and other wealthier countries. Covid-19 is forcing us to recognize social inequity as a source of shared vulnerability.
Ensuring global health equity as a cornerstone of our strategy will be critical to ending the pandemic.
Anne N. Sosin, is the program director of the Center for Global Health Equity at Dartmouth College in Hanover, N.H.