The COVID-19 Weakest Links

SINGAPORE – No health system in the world has the surge capacity to cope with an influx of tens of thousands of patients in a matter of weeks, as is the case with the COVID-19 pandemic. Add in the fact that about one in seven people diagnosed with the virus will require hospitalization, and that about one in 20 will need mechanical ventilation, and you have a recipe for systemic overload and breakdowns.

If developed countries with efficient health systems are struggling to mount an effective response to COVID-19, then what hope do far weaker systems have? After all, poorer countries generally lack the technology, training, and resources to find those infected with the virus, isolate them in suitable facilities to minimize onward transmission, and treat them adequately in order to minimize morbidity and mortality.

These countries also tend to be weaker in standard epidemiological responses such as contact tracing, as well as in procuring and ascertaining a steady supply of personal protective equipment (PPE) for frontline health-care workers. True, more authoritarian regimes (which a number of poor countries undoubtedly are) may be able to impose more stringent forms of mandatory social distancing. But they may be less able to mitigate the negative consequences of such measures, especially for socioeconomically disadvantaged groups.

So, what can countries with weak health systems do in the face of the COVID-19 pandemic?

Locking down borders minimizes importation risk and gives national health systems additional time to prepare their workforces. But for countries that often rely on external aid for essential goods and services, including medical supplies, a complete border shutdown could trigger a humanitarian crisis.

Moreover, the COVID-19 virus spreads most efficiently during the first few days of symptoms, when the disease typically is mild. Yet, in many poorer countries, people see a health-care provider only after they have been sick for much longer or become severely ill. Most will continue to work in the interim to maintain an income for their family. To prevent this, governments and community leaders will need to increase health literacy and establish financial safety nets to protect against widespread poverty – but that is easier said than done.

In addition, many low- and middle-income countries (LMICs) still rely on community-health workers to provide basic primary care, especially in rural areas. But these citizens may be the most exposed and at risk when there is widespread community transmission, especially if they lack the necessary PPE to protect themselves. Many of them also will be unable to distinguish the symptoms of COVID-19 infections from those of other influenza-like illnesses. All frontline health-care workers therefore must be trained in the effective use of PPE to minimize infection risk (and equipped accordingly), and understand how to triage and isolate suspected COVID-19 infections.

Moreover, in many LMICs, health-care professionals in tertiary hospitals (which offer the broadest range of services) will need additional instructions regarding intensive-care management of the most severe COVID-19 cases. This requires the careful coordination of teams of three to five health-care workers to provide round-the-clock clinical oversight.

Accurately diagnosing a COVID-19 infection requires dedicated laboratory facilities to perform the genetic RT-PCR test on specimens of sputum or nasal swabs collected from suspected cases. But poor countries often lack access to the genetic technology and trained lab technologists needed to run these tests, and must rely on aid from international partners to plug the gaps.

The inability to diagnose COVID-19 infections accurately also confounds the process of contact tracing – identifying the people who have been in recent contact with someone known to have COVID-19, and who thus may be similarly infected. Moreover, establishing these linkages requires dedicated trained personnel to conduct interviews and investigate. Indeed, there is worldwide concern that the low number of reported COVID-19 cases in many poorer countries reflects their weaker capacity to test and trace, rather than the virus not having established a foothold there yet.

In planning their national response to COVID-19, therefore, leaders of LMICs need to recognize where the gaps are, whether in the number of health-care and epidemiological professionals, the amount of clinical infrastructure, or supplies of medical equipment. Having identified these gaps, governments can then reach out to the World Health Organization and well-resourced trade partners for support and advice. Here, China has emerged as a leading global provider of international aid in the form of both supplies and technical advice.

The COVID-19 pandemic is a global crisis of the sort the world has not experienced in generations. Policymakers must therefore go beyond country-level responses to the virus and mount a coordinated global effort, in particular by ensuring that technical expertise and resources are common goods to be shared.

Just as a chain is only as strong as its weakest link, so the failure of a single country to contain COVID-19 heightens the risk to the rest of the world. Countries with stronger health systems must now urgently assist their weaker counterparts, which in turn should readily accept any aid that helps them tackle this deadly global threat.

By Yik-Ying Teo

Yik-Ying Teo, Dean of the Saw Swee Hock School of Public Health at the National University of Singapore (NUS), is Founding Director of the Centre for Health Services and Policy Research at Singapore’s National University Health System (NUHS), and a former director of NUS’s Centre for Infectious Disease Epidemiology and Research.

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