1) International Development Committee: Humanitarian Crises Monitoring
Executive Summary:
The following submission draws on cross-disciplinary expertise from the London School of Hygiene & Tropical Medicine (LSHTM) to offer comment on the COVID-19 pandemic in the context of low- and middle- income countries (LMICs), with particular emphasis in humanitarian settings. This includes the COVID-19 situation in LMICs and the potential for spread, and the risks specific to humanitarian settings, where social distancing and other measures shown to be effective in high-income settings may not be feasible. Learning from key lessons from previous epidemics including Ebola, such as community engagement, and transparent, coordinated responses tailored for specific settings, can strengthen approaches to current and future health threats. Humanitarian settings are likely to face particular contextual challenges in tackling COVID-19, such as economic social and cultural inequalities, lack of personal protective equipment (PPE), human resources and equipment, human resources and equipment, and the additional health burden of communicable and non-communicable diseases, including mental health. The UK should continue its support for the COVID-19 response in LMICs; the pandemic presents an opportunity to learn and act upon the lessons from the past, integrating and ingraining sustainable investments in global health to bring benefits of a healthier planet for all.
Institutional Context:
This is an institutional submission from LSHTM, an institution renowned for its research and education in public and global health. The School has an international and collaborative ethos, and is uniquely placed to help shape health policy and translate research findings into tangible impact, and address major health inequalities and challenges. LSHTM deploys research in real time in response to crises, developing innovative programmes for major health threats. In addition, the UK the UK Public Health Rapid Support Team (UK-PHRST), which is jointly run by LSHTM and Public Health England, rapidly deploys public health experts at 48 hours’ notice to strengthen a country’s response to outbreaks. These specialists in epidemiology, infection control, laboratory diagnostics, social science, and clinical care work with public health specialists and scientists already on the ground.
The Health in Humanitarian Crises Centre at LSHTM brings together over 150 researchers of different backgrounds from all three LSHTM Faculties. Humanitarian crises due to armed conflict, natural disasters, disease outbreaks and other causes are major contributors to ill health and vulnerability worldwide. The persisting effects of crises on health and health systems can undermine decades of social development. The Centre’s focus is in improving the health of populations affected by humanitarian crises through quality research, teaching, training and dissemination of objective, evidence-based information. Research is currently ongoing across sub-Saharan Africa, Asia and the Middle East: from the conflict in the Democratic Republic of Congo, to South Sudan’s civil war, to Rohingya populations in Bangladesh, and Centre members and LSHTM researchers are working to respond quickly and effectively to the COVID-19 pandemic.
Humanitarian Crises Monitoring
The spread of SARS-CoV-2 / COVID-19 now includes all substantially populated regions in the world, including lower- and- middle income countries (LMICs). While the apparent local spread in these countries, at least those outside the Asia-Pacific region, may have lagged behind Europe & North America, nearly all now report ongoing community transmission. Due to surveillance challenges in LMICs generally, even those not reporting community spread may be experiencing it.
Almost all LMICs have adopted official policies to slow transmission of COVID-19 through physical distancing and travel restrictions, though the specifics vary. The local impact of these interventions is not currently known, nor is the sustainability of these measures. Some countries with sufficiently low incidence and developed surveillance and laboratory capacity may be able to mount effective test-trace-isolate responses. However, as illustrated with other outbreaks and epidemics in these settings such as Ebola virus disease, which is easier to identify syndromically and much less transmissible than COVID-19, effective implementation can be difficult to achieve.
Based on knowledge from LSHTM participation in larger institutional responses, such as those led by WHO-AFRO and Africa CDC, we have seen that many LMICs are using mathematical models for forecasting, but most are relying on generic tools published by groups outside LMICs with limited local tailoring. They are also hampered by less mature health surveillance systems with lower reporting rates, longer reporting lags, and less testing capacity. LSHTM and other groups are working to provide customised analyses, but modelling projections will likely have large margins of error until more detailed country- and region-specific data are available.
It is not yet clear how COVID-19 will impact LMICs; most have the benefit of younger populations, particularly in more dense urban settings, but have much higher rates of other infectious diseases and not-insignificant rates of chronic disease. Understanding the risk of co-morbidities will be critical to estimating the real COVID-19 future burden. Similarly, the trends in hospital-settings - e.g., typical treatment times, mortality rates - are not yet known. Data from high-income countries suggest that 5% of symptomatic COVID-19 cases will require ventilation or become critical, 15% of patients with severe disease will need oxygen and 80% of cases will be mild or asymptomatic, requiring basic care at most. If the epidemic proceeds in LMICs with the severity rates seen elsewhere in the world, the demand for critical health care services will rapidly overwhelm local capacity. If the current intervention policies fail, health systems in LMICs will quickly devolve to triaging care and we can expect the more extreme levels of excess mortality.
In African countries, recent evidence suggests that public health strategies combining self-isolation of cases and suspects, moderate ‘social’ or physical distancing by the general population and shielding of individuals at high-risk from complications of COVID-19, could achieve substantial reductions in mortality due to COVID-19. However, in many humanitarian settings these measures are unlikely to be feasible and also unlikely to reach sufficiently high levels of adherence to reduce community transmission, especially in places where they will threaten people’s livelihoods. Based on the context, humanitarian actors will need to work closely with communities to select, adapt, implement and monitor a range of preventive approaches, e.g. adapting food distribution and other essential services to meet physical distancing requirements, creating ‘shielding green zones’ of vulnerable populations in urban settings and camps, and evacuating crowded facilities. However, the implementation of these approaches must consider economic inequities and vulnerabilities and how the most harmful effects of public health approaches can be mitigated. Community engagement processes which are inclusive and work with legitimate and trusted leaders will be instrumental in ensuring that interventions are contextually appropriate and effective. The LSHTM’s Health in Humanitarian Crises Centre, in partnership with the Johns Hopkins Center for Humanitarian Health and the Geneva Centre of Education and Research in Humanitarian Action have launched a website for humanitarian actors to share innovations and adaptations to their programming in their responses to COVID-19.
Evidence from previous epidemics, including the Ebola virus outbreak in West Africa (2013-16) and the Democratic Republic of the Congo (2018–present), show that the indirect health effects of an outbreak may result in greater morbidity and mortality from ‘non-target’ diseases than from the one causing the outbreak, underscoring the importance of prioritising continuity of essential health services. These include immunisation services, maternal and child care, and care for both non-communicable diseases (e.g. diabetes, hypertension) and key communicable diseases (e.g. TB, HIV/AIDS, malaria) which can be delivered, if necessary, via alternative service delivery modalities.
The anxiety and distress associated with fear of infection, loss of loved ones, and concern over access to basic needs and emotional support during isolation, is well recognised. A substantial rise in anxiety, depression and worsening of pre-existing mental health conditions has been measured not only in surveys but in increased demand for helplines and other support mechanisms. In developing countries, several of these concerns are accentuated. People living on subsistence incomes have few reserves to cope with an economic downturn, or movement restrictions. Isolation and physical distancing is impossible to achieve in crowded informal settlements, also increasing anxiety, and in some cases fuelling protest and behaviour that impacts negatively on interruption of transmission. Maintaining social relationships is the single most important promoter of wellbeing during challenging times, but online communication cannot be relied upon to replace social or work-related contact in many countries. Health systems are poorly equipped to provide an adequate response to mental health needs that arise, and experience of Ebola and other outbreaks is that people with severe mental conditions, particularly in institutions, are at great risk of neglect.
In the current national and international response, appropriate measures to promote wellbeing and support mental health must be put in place, including to address the mental health impacts of response measures. Such considerations not only have inherent value, but are essential to achieving optimal results, for example in compliance to behavioural recommendations, including eventual uptake of vaccines.
The UK has been extensively involved in the response to COVID-19 in LMICs. The UK Public Health Rapid Support Team (UK-PHRST), co-led by Public Health England and LSHTM, initially deployed personnel to a number of LMICs at the request of WHO, Africa CDC, and national governments to provide support in epidemiology, data analysis, infection prevention and control, clinical care, laboratory diagnostics, social science, logistics, and strategic guidance. These included deployments to the Philippines, Nepal, Ethiopia, and Nigeria, with others planned until travel and flight restrictions forced recalling of all personnel back to the UK. Nevertheless, the team continues to provide remote support to the aforementioned international stakeholders as well as remote engagement with the WHO African Regional Office in the Republic of the Congo and WHO Country Office in Bangladesh (Dhaka, with work focused on the displaced Rohingya population in Cox’s Bazaar). LSHTM and the UK-PHRST have also developed a COVID-19 Massive Open Online Course, with over 200,000 registrants from over 184 countries. The course has been translated into Spanish, Portuguese, French, Italian, Mandarin, Arabic and Swahili and is now included in the training for Africa CDC’s African Volunteer Health Corps.
The DFID UK Emergency Medical Team and UK-Med are similarly engaged in providing clinical support to a number of LMICs, including Burkina Faso, Bangladesh, Zambia, and Ghana. Various UK academic institutions have also engaged in the response to COVID-19 in LMICs, such as LSHTM’s support for COVID-19 disease modelling in Asia and Africa, and numerous COVID-19 research endeavours with LMIC partner institutions. Many UK NGOs are also engaged in the COVID-19 response, although often hampered by the global travel restrictions and severely fractured global supply chain.
The UK also provides significant indirect support for the COVID-19 response to LMICs through its financial support to WHO (the second largest donor to WHO) and upcoming support for Africa CDC, as well as through participation on the WHO Global Outbreak Alert and Response Network (GOARN) Steering Committee and GOARN Research Working Group.
What should be the UK’s response going forward?
In the short term, we urge UK parliamentarians to continue their support for the above activities and actions and to encourage the UK government to take swift action and give generously to COVID-19-specific global humanitarian response funds. This should not be at the expense of diverting funds intended for preventive health programmes in LMICs that can help reduce the burden on their health system for acute care needs from COVID-19. In the long term, countries need to be supported to invest in strengthening health systems, particularly human resources, which can provide protection in times of crisis. Moreover, global, regional and national actors need to maintain a focus on understanding and addressing the social determinants of health. Across the world, the COVID-19 pandemic and responses to it have revealed immense social inequalities that are being magnified during this global crisis. The capacity of health systems in LMICs to screen, let alone treat, COVID-19, will be very limited. In South Africa, each test costs around $75 (£60) – this exceeds total government per head health spending in many LMICs, such as Bangladesh ($34), Benin ($30) or Haiti ($38). N95 masks are in short supply and cost around $9 each in South Africa. In many settings, including those affected by humanitarian crises, people in poorer socio-economic circumstances are more likely to suffer from chronic diseases such as high blood pressure, diabetes and heart or respiratory disease which can cause severe complications in COVID-19. They are also more exposed to infection through an inability to self-isolate because of insecure labour conditions and more crowded living conditions. Economic assistance programmes should reinforce initiatives to build social protection systems in LMICs.
While the COVID-19 pandemic has demonstrated in high income countries how much employment can continue through remote working, it has also laid bare the vulnerabilities of LMICs and inefficiencies of an international response and supply architecture that is still overly dependent on research-rich countries. Many LMICs still have severe shortages in the trained healthcare and public health workforce, and very limited local or even regional production of medical and research supplies, therapeutics and vaccines. These weaknesses become particularly evident when the global travel and supply chain becomes severely fractured, as has happened with COVID-19.
Many LMICs have made great strides in the last few decades in developing international and national public health institutions (e.g. Africa CDC, Nigeria CDC), with the potential for effective partnerships for transformative change in health. The UK should continue to support these institutions, as well as the educational systems that feed into them, with funds and training that will allow them to fully emerge as autonomous entities to guide and implement outbreak responses that are not overly dependent on short-term support or expertise from the UK, WHO Geneva, or US CDC. Such investment promises benefits not only in LMICs, but also in the UK, as the global threat of outbreaks, and importation into the UK, will only increase.
No relevant expertise
Detailed social science research on the West Africa Ebola outbreaks in 2013-2016 (Guinea, Liberia and Sierra Leone) and 2017-ongoing (Democratic Republic of Congo - DRC) hold many critical lessons for tackling Covid-19 and other epidemic outbreaks in fragile and humanitarian settings.
First, building trust was the biggest challenge to Ebola response efforts. Many international responders in the DRC crisis called for a “rethink” on how operations were being handled, in a context of pre-existing and soaring distrust of foreign presence. As one group recognised “the best way to overcome this distrust is to trust the community”. Detailed ethnographic and health systems work from Sierra Leone shows that community-level distrust was related to the nature of the response, and the distance to the locus of operational decision making. Key actions that transformed the response were the decisions to site treatment centres closer to communities and widespread recruitment of local volunteers to conduct contact tracing, safe, dignified burials and build local response plans – including handwashing stations, identifying local isolation spaces, overseeing quarantine compliance, and collecting and dispelling myths and rumours.
Second, it is of critical importance to identify and work with a range of (locally perceived) authorities. In Sierra Leone, international responders needed to work with district and traditional authorities, as well as health workers embedded in communities, to discover other local leaders and figures of influence including women‘s groups, secret societies and religious groups, traditional healers, citizen welfare groups, youth organisations and so on. In DRC, the exceptionally difficult humanitarian context, with multiple militia groups and widespread poverty and weakness of health systems, made this particularly challenging. Nevertheless, great efforts were made by international and national responders in parts of North Kivu and Ituri Provinces in DRC to identify and work with people who were perceived to be legitimate figures of authority, even if they did not have legislative or official authority. Considerable effort was also given to working with researchers (social scientists, including anthropologists and health systems researchers) with extensive knowledge of the region to map out different kinds of public authority. Recording how these different authorities related to each other enabled responders to identify and establish effective working relationships with, for example, particular youth groups and militia groups in parts of North Kivu and Ituri Provinces.
Third, it is also important that efforts to engage, learn from and work with communities should be implemented in a locally appropriate manner. In DRC, failure to engage local groups and leaders in some areas and the inappropriate prominence of the international response – driving in and out of affected areas in expensive vehicles, surrounding facilities with orange tape, conducting communications and training largely in French, a language not understood by many villagers – led to a counter-discourse of Ebola denial, feeding attacks on Ebola facilities and staff and fuelling massive distrust of the response. Part of meaningful engagement involves listening to and being prepared to learn from local responders. In humanitarian crises settings, like the DRC, afflicted by historic insecurity, ongoing conflict, weak medical systems, high mortality and morbidity, survival requires skill and tenacity, a capacity to learn from the past and to draw on local knowledge. In these contexts, placing greater trust in communities to identify effective solutions is likely to pay dividends. Ebola in Sierra Leone taught international responders never to underestimate the levels of skill, common sense and adaptive ingenuity of local agents (from health workers and district managers to family members) to respond to Ebola once they understood the nature of the challenge, provided there was a real attempt to build working alliances between local and international partners based on mutual respect.
In conclusion, key lessons from the West Africa Ebola response, for humanitarian contexts are: to establish trust to enable effective localised response; this can be achieved by i) working closely with different forms of local authority, including recognizing heterogeneity and different capacities among those authorities, with a commitment to allowing local authorities to shape the response; and ii) allowing local frontline health workers and community leaders to advise international responders on the best means to reach and encourage cooperation from affected communities and support the expansion of surveillance beyond those reached by formal health systems or emergency responses.
Myths about migration and health, including that migrants are disease carriers and are a burden on services, are not supported by the available evidence and ignore the critical contributions that migration makes to global economies. Nevertheless, displaced populations, including refugees, have been stigmatized, scapegoated and neglected in the emergency response to COVID-19. Previous epidemics have shown that stigmatising disease transmission only further places stigmatised populations at risk and reduces their access to care. Inciting stigma aimed at foreigners or minority groups furthermore undermines trust in community engagement efforts which are needed for an effective, whole-of-society epidemic response. Conflict-affected populations, as well as the healthcare workers who serve them, should have access to healthcare resources and innovations alongside all populations. Moreover, people fleeing war in an epidemic still need protection, regardless of real or perceived fears of COVID-19. Border controls must balance the needs to control infections and protect peoples’ right to asylum so that entry is safe for everyone.
No relevant experience
COVID-19 will inevitably change the health and economic trajectory of countries around the globe. While the economic impacts may be severe in some sectors, the UK and its global partners must resist the urge to economize with regard to health investments, including in the capacity for outbreak response, in LMICs. History and detailed post-outbreak analysis show that, in addition to the lives lost, the economic costs of the emergency response to outbreaks is almost invariably far greater than the investments that would have been needed to prevent them. Pandemics and outbreaks can provide opportunities to begin to enhance the health infrastructure of vulnerable countries.