Perspectives
The art of medicine
Has COVID-19 subverted global health?
For the first time in the post-war history of epidemics, there to die in the millions of other diseases, and lockdowns have Published Online
is a reversal of which countries are most heavily affected by a made accessing essential health care much more difficult in May 5, 2020
[Link]
disease pandemic. By early May, 2020, more than 90% of all some places. In India, for example, public transport, the main S0140-6736(20)31089-8
reported deaths from coronavirus disease 2019 (COVID-19) way for the poor and many health-care workers to reach a
have been in the world’s richest countries; if China, Brazil, health facility, has been barred since late March, although a
and Iran are included in this group, then that number rises limited restoration was announced on May 4, 2020. Not
to 96%. The rest of the world—historically far more used to surprisingly, there have been dramatic reductions in essential
being depicted as the reservoir of pestilence and disease that public health and clinical interventions; data from India’s
wealthy countries sought to protect themselves from, and National Health Mission indicate that there was a 69%
the recipient of generous amounts of advice and modest reduction in measles, mumps, and rubella vaccination in
amounts of aid from rich governments and foundations— children, a 21% reduction in institutional deliveries, a 50%
looks on warily as COVID-19 moves into these regions. reduction in clinic attendance for acute cardiac events and,
Despite this reversal, however, the usual formula of surprisingly, a 32% fall in inpatient care for pulmonary
dispensing guidance continues to be played out, with policies conditions in March, 2020, compared with March, 2019.
deemed necessary for the hardest-hit wealthy countries Similar reports are emerging from other countries, including
becoming a one-size-fits-all message for all countries. disruptions to insecticide-treated net campaigns, access to
Two centrepieces of this approach are the use of widespread antimalarial medicines, and suspension of polio vaccination.
lockdowns to enforce physical distancing—although, it is Twinned with lockdowns to achieve physical distancing is
notable that a few wealthy countries like Sweden and South the promotion of widescale COVID-19 testing that relies on
Korea have not adopted this strategy—and a focus on expensive kits and an emphasis on intensive-care units and
sophisticated tertiary hospital care and technological ventilator capacity. These strategies, which have dominated Further reading and viewing
solutions. We question the appropriateness of these much of the health-system response in rich countries, Patel V. India’s tryst with
particular strategies for less-resourced countries with distinct are a remote possibility in many low-resource contexts COVID-19. The India Forum,
April 17, 2020. [Link]
population structures, vastly different public health needs, where access to intensive care or anything beyond basic [Link]/article/indi-s-
immensely fewer health-care resources, less participatory diagnostics is far from universal. If COVID-19 vaccines are tryst-covid-19 (accessed
governance, massive within-country inequities, and fragile developed, history suggests they are likely to be available April 30, 2020)
economies. We argue that these strategies might subvert first in the countries that can afford to purchase them and Mushfiq Mobarak A,
Barnett-Howell Z. Poor countries
two core principles of global health: that context matters and only then will they trickle down to low-income countries, need to think twice about social
that social justice and equity are paramount. where they will reach the wealthy first. By contrast, distancing. FP News,
Context is central to the control of any epidemic, a truism there is barely any mention of the role of syndromic April 10, 2020. https://
[Link]/2020/04/10/
we’ve known for centuries but that we seem to have diagnosis (clinical diagnosis based on the constellation of poor-countries-social-
overlooked in this pandemic. Perhaps this is unsurprising symptoms and signs which are a hallmark of infection); the distancing-coronavirus/
given the colonial history of medicine, in which the illnesses role of community health workers, primary care nurses, (accessed April 30, 2020)
that affected Europeans were assumed to have universal
significance whereas those that affected the non-European
populations who were colonised were relegated to “tropical
medicine”. That context matters is obvious in the case of
COVID-19. Low-income and lower-middle-income countries,
clustered in sub-Saharan Africa and south and southeast
Asia, have a different demographic profile from wealthy
countries of the OECD and east Asia. Their populations are
much younger and most older people live at home, not in
care homes, where up to half of all deaths in wealthy countries
have occurred. Just these variations in age structure and
social arrangements account for lower risk of COVID-19
mortality in these populations. Yet lockdowns have been
Reuters/Danish Siddiqui
imposed in these countries.
The number of deaths from COVID-19 since the epidemic
began is a tiny fraction of all deaths that have occurred due
to any cause since the start of 2020. Thus, people continue
[Link] Vol 395 May 30, 2020 1687
Perspectives
Mugabi I. COVID-19: Security and doctors; and the role of community engagement. non-intrusive interventions that are possible without
forces in Africa brutalizing Constrained health-care systems already short of money, disrupting the intrinsic fabric of society. Central to our
civilians under lockdown.
Deutsche Welle, April 20, 2020.
beds, equipment, and staff, are unlikely to be able to provide proposals are the engagement and participation of all
[Link] treatment for COVID-19 patients unless they reallocate sections of the community, especially the poor and
19-security-forces-in-africa- scarce resources. And so, the combined effect of the reduced marginalised, as a mature and responsible citizenry, invoking
brutalizing-civilians-under-
lockdown/a-53192163 (accessed
access to, and availability of, essential health care might lead their solidarity to be part of a shared endeavour, rather
April 30, 2020) to increases in deaths unrelated to COVID-19. than seeing the goal of containing COVID-19 as a purely
Rukmini S. How COVID-19 A second key principle of global health is social justice and technocratic or law-and-order problem. Similar community-
response disrupted health equity: the concerns of the poor who already bear a dis based strategies of social mobilisation and engagement were
services in rural India.
April 27, 2020. [Link]
proportionate burden of risk factors and disease must be at effective in reducing transmission of Ebola virus disease in
[Link]/news/india/how- the centre of all decisions. Yet a one-size-fits-all approach to west Africa.
covid-19-response-disrupted- COVID-19 has not only been inequitable in its impact, but is Concurrently, we suggest that countries must let people
health-services-in-rural-
also likely to increase inequalities in the long term. A stark get on with their lives—to work, earn money, and put food
[Link]
(accessed April 30, 2020) example is the inequitable economic impact of lockdowns on on the table. Let shop keepers open and sell their wares and
The Lakshmi Mittal And Family people who barely survive on precarious livelihoods. About provide services. Let construction workers return to building
South Asia Institute, Harvard 2 billion people make their living in the informal economy, sites. Allow farmers to harvest their crops and to transport
University. The response to and over 90% of them live in low-income and low-middle- them to be sold on the open market. Allow health workers to
COVID-19 in South Asia.
April 23, 2020. https:// income countries. Hunger is an immediate threat to these do their daily work as before, with sensible precautions such
[Link]. people and their families, both due to the loss of daily wages as use of gloves and masks to minimise the risk of exposure
edu/2020/04/video-the- and the disruption of the food supply chains. The UN has to the virus. And allow the average citizen to travel freely with
response-to-covid-19-in-south-
asia/ (accessed April 30, 2020)
estimated that over 300 million children who rely on school restrictions only applied to clusters where lockdowns are
Blavatnik School of
meals for most of their nutritional needs might now be at risk necessary. Livelihoods are an imperative for saving lives.
Government, Oxford University. of acute hunger, which could reverse the progress made in Some will say such an approach, which runs the risk of
Relationship between number the past 2–3 years in reducing infant mortality within a year. spreading disease, implies that the lives of poor people are
of COVID-19 cases and
government response. 2020.
Then there is the practical challenge of physical distancing not as valuable as those in wealthy countries. Nothing could
[Link] and quarantining in urban slums and rural households where be further from the truth. The policies of widespread
uk/stringency-map (accessed multiple people share a room and where toilets cater for lockdowns and a focus on high-technology health care might
April 30, 2020)
many families. Lockdowns have been enforced with an unintentionally lead to even more sickness and death,
International Labour
Organization. More than 60 per
increase in authoritarian behaviour of the police with the disproportionately affecting the poor. And, if such policies
cent of the world’s employed poor experiencing brutality and humiliation in countries such are mandated by global consensus, then global financial
population are in the informal as India, Nigeria, Kenya, and South Africa. In sharp contrast, institutions must write off outstanding debts from low-
economy. April 30, 2020.
lockdowns are little more than an inconvenience for affluent income countries and finance the needed resources to
[Link]
about-the-ilo/newsroom/ people, who typically look to high-income countries as the underwrite the economic recovery of these countries.
news/WCMS_627189/lang--en/ model to shape their view of how society should respond to Key principles of global health are context and equity.
[Link] (accessed the pandemic. We urge less-resourced countries to devise policies that speak
April 30, 2020)
What then should these countries do, especially as some of to their unique demographics, diverse social conditions
George L. COVID-19 is
exacerbating food shortages in them begin to ease lockdown restrictions? Realistically, a and cultures, precarious livelihoods, and constrained
Africa. World Economic Forum, community-based approach is needed that emphasises infrastructure and resources. A focus is needed on what is
April 27, 2020. [Link] active case finding (through syndromic diagnosis where possible, acceptable, just, and sustainable. Given that
[Link]/agenda/2020/04/
africa-coronavirus-covid19-
laboratory-confirmed diagnosis is not available) by com substantial financial support from wealthy countries—in
imports-exports-food-supply- munity health workers and primary care providers, with contrast to technical guidance—is unlikely, low-resource
chains (accessed April 30, 2020) contact tracing and home quarantining, especially early in an countries need to rely on their own home-grown expertise,
Giles C, Mwai P. Coronavirus: epidemic, engaging and enabling community resources with grassroots experience, and community resources to chart a
the different approaches to
lockdowns in Africa.
due attention to avoiding stigmatisation, and banning mass way through this crisis. In addition to being aligned with the
BBC, April 28, 2020. gatherings. District-level facilities for appropriate respiratory founding principles of global health, such policies would
[Link] support that can be managed by locally available human adhere to a principle of the Hippocratic Oath “primum non
world-africa-52395976
(accessed April 30, 2020)
resources, equipped with adequate personal protection, need nocere”—”first do no harm”.
United Nations Sustainable
to be developed as long-term assets for the health-care
Development Group. Policy brief: system. Lockdowns, if humanely planned and with the Richard Cash, *Vikram Patel
the impact of COVID-19 on participation of the community affected, could be used Department of Global Health and Population, Harvard T H Chan
children. April 15, 2020. School of Public Health, Boston, MA, USA (RC); and Department
sparingly to contain clusters of cases. Wearing masks at home
[Link]
policy-brief-impact-covid-19- for the ill person and caregiver, washing hands when possible, of Global Health and Social Medicine, Harvard Medical School,
children (accessed practising coughing etiquette, and physically distancing Boston, MA 02115 USA (VP)
April 30, 2020)
older people and those with comorbidities are a few of the vikram_patel@[Link]
1688 [Link] Vol 395 May 30, 2020