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If not addressed soon, the inadequate disease control systems in developing countries are likely to cause spikes in coronavirus cases that might impact the globe, experts say

By Cao Ran Updated Jun.1

People gather to pray during the Covid-19 pandemic, Nairobi, Kenya, March 29, 2020

On April 7, the government of Zanzibar, a semi-autonomous region in Tanzania, designated five schools as temporary quarantines. Zanzibar had seven confirmed cases of Covid-19, mostly imported from Europe. Local health officials told NewsChina that all the cases were mild and patients were in hospital receiving treatment.　

The World Health Organization (WHO) warned of the Covid-19 spread in Africa, particularly in Tanzania, Kenya and South Africa. As of April 6, African countries had 9,457 confirmed cases and 442 deaths. South Africa and Egypt, which boast the best public health systems in Africa, have the most confirmed cases.　

Many developing countries in other parts of the world are also under growing pressure from the epidemic. By April 6, Brazil had 11,281 confirmed cases. India reported over 4,000. 　

According to John Nkengasong, head of the Africa Centres for Disease Control and Prevention, if cases escape detection, the poverty, social instability and weak healthcare systems in some countries could exacerbate the pandemic and potentially have a global impact.　

Zhang Wenhong, director of the Department of Infectious Diseases under Huashan Hospital affiliated with Fudan University, called for the world to unite and help countries with inadequate medical resources to combat the disease. “The success of the battle hinges on countries with the poorest public health systems, rather than the opposite,” he said.　

Mission Impossible

In Zanzibar, whenever authorities find a suspected case, medical institutions will take samples and send them to Dar-es-Salaam, capital of Tanzania. It usually takes three days to get the test results. Sara Nieuwoudt, a lecturer at the School of Public Health, University of Witwatersrand in South Africa, said there are vast differences in health systems on the African continent.　

“Countries that have centralized systems to coordinate responses and strong supply chains will do better to prepare for any significant increases and rolling out interventions such as testing,” she told NewsChina. “Countries like South Africa, which have existing surveillance and testing infrastructures, will adapt more quickly than more poorly resourced counterparts in the region.”　

When Covid-19 first appeared in Africa in February, only the Institute Pasteur in Senegal and the National Institute for Communicable Diseases in South Africa were equipped to detect cases. Even though over 30 African countries could detect the virus by April, most laboratories are in capitals and major cities, making widespread detection efforts difficult.　

The WHO requires that all countries report new contagious diseases immediately. When H1N1 struck in 2009, Benjamin Cowling, a professor at the School of Public Health at Hong Kong University, argued that it was nearly impossible for developing countries with ill-equipped laboratories to report data to the WHO.　

“China was not counting the asymptomatic infections either [early in the outbreak]. With limitations on testing capacity, priority should go to symptomatic persons. If there is enough capacity, we can also consider testing asymptomatic persons,” he said.　

During a press conference at WHO headquarters in Geneva in February, a representative of Sudan said: “We are fighting six epidemics now. We don’t need another one.” Sara Nieuwoudt told our reporter that health systems in South Africa were already “under a huge strain before the coronavirus.”　

Since February 2020, most “patient zero” cases in Africa came from Europe. Starting from March, most governments in Africa vowed to control imported cases from Asia and Europe. Instead of air and sea travel, many developing countries in Asia, Africa and Latin America see larger travel volumes on their roads and rivers, which pose an even greater challenge to monitoring population flows.　

Because it is difficult to assess accurately the epidemic in developing countries, Cowling said the international community must establish a monitoring protocol based on symptoms and systematic virological testing rather than just monitoring confirmed cases.　

Double-edged Sword

Since April, the Dharavi slum in Mumbai, India has been unusually still. Military police officers blocked the entrance and epidemic prevention personnel disinfect the empty streets regularly. As of April 7, there were three confirmed cases, including two deaths.　

In many developing countries, slums and poor communities have large population concentrations with weak health infrastructure. Some even lack clean water. In others, authorities struggle to push basic practices such as frequent hand washing. Also, malnutrition is common in these areas, which further increases risk of disease.　

Nineteen countries reported more than 100 deaths between March 29 and April 5. The increase is leaving many developing countries in limbo, particularly those with weak public health systems. In India, there are only 1.31 beds per 1,000 people, far below many developed countries. 　

Conditions are even worse in some African nations. A Chinese doctor who has served on medical missions to Africa told NewsChina that Zanzibar has no ICUs, ventilators and negative pressure isolation rooms. Its largest hospital is smaller than most county hospitals in China. “We brought all our medical supplies from China when we worked in Zanzibar,” he said.　

Public health spending per capita in most African countries is less than US$20 each year, far below the US$34-40 set by the WHO. African medical workers account for 1.3 percent of the world total, but they handle 25 percent of disease treatment globally. On thecontinent, 13 countries met the WHO’s minimum standards - one hospital per 100,000 people.　

Since the global spread, community-centered isolation has been the only anti-epidemic method available to many developing countries. On March 24, India declared a 21-day “complete lockdown” to stop the coronavirus which was extended to May 3. Meanwhile, many countries in Africa announced a state of emergency: 53 countries closed schools and canceled public activities and 43 countries closed their borders. 　

Sara Nieuwoudt said public trust in the health system is critically important and wealth does not automatically translate to effective responses if key influencers, such as religious leaders, are not part of the response. 　

“We have seen this in countries like Nigeria, where religious leaders have actively worked against polio vaccination campaigns. The same could happen with coronavirus responses unless such individuals are involved in promoting public health,” she said.　

In countries with inadequate medical resources, lockdowns are double-edged swords. Lagos, the biggest city in Nigeria with a population of 20 million, has strictly controlled transportation and population flows since the outbreak of Ebola, successfully preventing its spread. In some cities far from the capital, however, isolation measures have resulted in rapid depletion of medical resources and growing death tolls.　

A United Nations report in 2015 stated that during the latter periods of Ebola, lockdown measures in some western African countries resulted in high school dropout rates, pregnancy and maltreatment. The Tanzania government recently announced that if it implemented a complete lockdown, many would starve to death.　

People maintain social distancing while lining up outside a bank in Srinagar, capital of India-controlled Kashmir, April 6, 2020

Epidemic Victims

“The only way out for these countries is support from the international community,” said Chee Yoke Ling, founder of the Covid-19 Clinical Research Coalition. In an article published in medical journal The Lancet on April 2, a newly established coalition of scientists, doctors, funders and policymakers from 30 countries wrote that to help developing countries combat the disease, it is urgent to construct a global cooperation framework, strengthen medical training for lagging countries, and build a supply chain of medicines and vaccines based on equality and mutual assistance.　

China’s SARS outbreak in 2003 prompted the WHO to create the International Health Regulations in 2007. The World Trade Organization (WTO) created an international cooperation mechanism to coordinate and share reports of any contagious diseases from member countries.　

During the H1N1 outbreak in 2009, the cooperation framework showed many weaknesses. In the article “Pandemic Preparedness and Response - Lessons from the H1N1 Influenza of 2009” published in the New England Journal of Medicine, author Harvey V. Fineberg summarizes that the world is ill-prepared to respond to a severe influenza pandemic or any similar sustained public health emergency.　

But unlike the WTO, the WHO does not have the power to sanction countries that break the International Health Regulations. When an epidemic occurs, each government combats the disease however they see fit. 　

Fineberg added that the contagious disease prevention system is only effective to handle regional emergencies, not a global pandemic.　

Chee Yoke Ling told our reporter that the recent coronavirus outbreak has depleted global medical supplies. Many countries ignored the appeals of the WTO and continued to issue export restraints and prohibitions. The poorest countries have become the biggest victims.　

“This makes us very, very concerned that when it comes to medicines and vaccines, instead of international cooperation and solidarity, we will see more grabbing and self-interest. The ugly face of inequality at the global level is starkly exposed by the pandemic,” she said.　

As of April 7, more than 70 countries and 20 medical R&D institutions have taken part in the Global Solidarity Project to ramp up clinical research on Covid-19 and share treatment and vaccine research. Meanwhile, some pharmaceutical companies have franchised their production of new medicines. 　

“We need to systematically increase production along the entire supply chain, and while this is really challenging with lockdowns everywhere,” Chee said.

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