Health and Healthcare Systems

‘Flattening the curve’ is a pipe dream for fragile countries

A girl wears a protective face mask at a makeshift camp for refugees and migrants next to the Moria camp, during a nationwide lockdown to contain the spread of the coronavirus disease (COVID-19), on the island of Lesbos, Greece April 02, 2020. REUTERS/Elias Marcou - RC2IWF9Q4OTQ

The first slew of coronavirus cases has hit refugee camps in Greece. Image: REUTERS/Elias Marcou

Zahra Bhaiwala
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  • The current focus of the COVID-19 pandemic internationally has been on “flattening the curve” to relieve stress on healthcare systems.
  • Many health systems in developing countries have been crippled by war.
  • Refugee camps, war zones, and blockaded territories are facing additional restrictions that threaten prevention, management and recovery in the inevitable event of an outbreak.
  • Addressing these access restrictions to protect our most vulnerable populations requires international policy change, innovation and collaboration.

At what seems like the nadir of COVID-19’s destructive path, New York City is amassing up to 125 unclaimed bodies every week in mass graves, with over 100,000 cases recorded and counting. Field hospitals have been set up in Central Park. The deployment of temporary refrigerated van-morgues from a few weeks ago already feels like a thing of the past.

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And yet, despite the destruction, New York City has evolved into an epicentre of international and multi-sector collaboration to overcome the crisis. Foreign governments, citizens, non-profit organizations, and manufacturers have rapidly mobilized support. Ventilators and personal protective equipment (PPE) have crossed international borders to fill resource gaps. Physicians and other healthcare workers from across the country have willingly left their homes on free flights to New York City to fight the pandemic together.

Many vulnerable populations will soon follow in New York City’s trajectory. The pandemic will hit Gaza, Yemen, and Syrian refugee camps in Lebanon like too many others, with drastic resource gaps. It is the addition of ongoing conflict and structural restrictions to receiving foreign aid – barriers that are man-made and systematic – that set these examples apart. Without the ability to collaborate or receive aid freely, the COVID-19 outbreak will be a catastrophe.

These regions, too, will surpass their systems’ threshold of care. Similar mass graves will be filled. Yet they will suffer these consequences knowing that relief has long since been systematically prevented from reaching them, and that this global pandemic was no exception.

A pipe dream for vulnerable populations

Flattening the curve has three components: “avoid contact”, “wash your hands”, and “stay calm”.

Avoiding contact, or social distancing, is a privilege that many vulnerable populations cannot afford. This is exacerbated in the Gaza Strip (over 150 times the population density of the US) and in the makeshift Syrian refugee camps of Northern Lebanon, where families of nine are crowded like sardines in tents less than six feet from their neighbours. These populations will remain crowded because they have been physically cut off from the rest of the world.

Washing your hands, at a minimum, requires access to water and soap. Over 90% of the water in Gaza has been rendered undrinkable as a result of continuous war and permanent damage to the sewage system. The 15-year blockade has long-since hindered procurement of raw materials to repair civil infrastructure; now it is keeping out life-saving PPE and essential supplies to build ventilators.

Similarly, NGOs like Endless Medical Advantage (EMA), a mobile health clinic serving 5,000 Syrian refugee patients in Lebanon’s Bekaa Valley, have been prevented until just a few days ago from entering the camps to deliver basic sanitation kits of alcohol and chlorine due to government restrictions in attempts to curb virus spread

Hospital beds per 1,000; ICU beds per 100,000; ventilators per 100,000; healthcare workers per 1,000.

With ongoing civil war bombarding Yemen for the last five years, “people are more worried about airstrikes than they are about wearing masks”, says the only obstetrics and gynecology doctor serving 1.2 million people in the north of the country, who works for one of the largest international humanitarian medical organizations. “I don’t think Yemen can handle COVID-19. We have cholera season coming up, diphtheria, dengue fever, and malaria and on top of that we are just trying to provide essential services while negotiating with multiple armed groups just 20 km from an active war zone.” Coupled with air strikes, these upcoming outbreaks, only exacerbated by the reality that handwashing is a luxury, make “staying calm” a chimera.

Healthcare workers have also been explicitly prevented from providing medical care to refugees. Physicians like Dr Feras Alghadban at EMA are using WhatsApp to assess patients from afar with the knowledge that the camps will face “a catastrophe if the virus infects even one refugee”. Without systematic electronic data collection, COVID screening and risk assessment are either porous or non-existent.

Infant mortality rate vs % of population below international poverty line.

COVID headlines today focus on increasing unemployment rates, skyrocketing prices of essential supplies, chronic shortages of qualified healthcare professionals and medical equipment – all phenomena that these vulnerable populations with institutional barriers to access have faced for years. These populations are not in quarantine, they have been trapped for a long time.

The sobering truth is that healthcare and politics are inextricably linked in Middle East and North African regions marred by conflict: healthcare will continue to suffer as political constraints on access continue to be imposed. Gaza has already run out of its 200 allotted COVID testing kits, and it is unclear when more will be let through the blockade. The first slew of cases has hit refugee camps in Greece, and during the time of writing this piece, the first case was reported in Yemen. It is the inability to receive aid during a crisis – the crippling access restrictions and ongoing violence – that is equally, if not more of a threat than the virus itself.

How do we remove these restrictions on access?

World leaders: This crisis calls upon you to redefine border restrictions and blockades. But in the wait for policy change, it is the intersection of innovation and collaboration that can lead us through.

Healthcare entrepreneurs: Push the envelope – organizations like MedicMobile and Hikma Health have built data solutions specifically for low-resource populations around the globe who need them most, providing free and open-source software.

Academic institutions: If your labs have working medical device prototypes – publish your protocols, form Slack groups with teams in countries with vulnerable health systems working on the same problem. Use technology to return to the spirit of hands-on science.

Public and private sector executives: Continue to repurpose your operations to fight this common enemy, whether your organization runs translation services or mixes high-end perfumes.


What is the World Economic Forum doing about the coronavirus outbreak?

The COVID-19 pandemic is a truly global phenomenon – the virus itself will not discriminate between the cells of a mother of five in Brooklyn or in Gaza. And yet this is not a democratizing experience. We must acknowledge a second pandemic, one that has a curve of its own: the structural inequity in health access caused by imposed borders, restrictions, and blockades. Unlike COVID-19, this pandemic is within our control.

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