Want to stop pandemics? Strengthen public health systems in poor countries

More than 200 countries now report COVID-19 cases, but if you happen to live in one of the world’s 35 low- and middle-income countries (LMICs), you could face a more dangerous situation. 

For the moment, those in LMICs are thankful they don’t yet have as many cases as does the world-leading United States. But they fear what could be coming.

That’s why, last week, India’s Prime Minister Narendra Modi announced a 21-day lockdown for the entire country of 1.3 billion people. Presently, a third of the world’s population is on some sort of lockdown because of the coronavirus. But for LMICs, preventing a pandemic is not so simple. 

Following the lockdown, scores of India’s 120 million migrant laborers left cities to return home en masse, in effect spreading the infection around the country. 

Because of overcrowding where poor people live and work, and on trains and buses, a great many who live in LMICs can’t practice effective social distancing.  

Because running water or soap are not readily available where they live or work, a great many in LMICs can’t practice frequent hand-washing. 

Because of weak health care organizations, hospitals may not be able to isolate suspected COVID-19 cases, and they certainly do not have sufficient personal protective equipment (PPE) for all doctors and other front line health workers, let alone intensive care unit beds and ventilators.

Then there are the world’s 70 million forcibly displaced persons who live in refugee camps or other overcrowded settings and have limited to no access to health care. In some countries, such as Syria, Afghanistan and Yemen, armed conflicts complicate the situation. 

We have been talking with health care colleagues from multiple LMICs, including India, Nigeria, Kosovo, Bangladesh and Tajikistan. Many of them have asked: “Without adequate social distancing, hand-washing, ventilators and PPE, what do you recommend that we do? How can we save lives?”

Honestly, we have no good answers. We know from prior pandemics that LMICs are likely to experience higher morbidity and mortality. We don’t want to give them news that could take away their agency, their hope. Not all LMICs, or all locations within LMICs, will have the same outcomes. 

We certainly do not want to underestimate the courage or innovations of health care professionals, who may yet find ways to save lives even in the most difficult of circumstances.

However, we know that this higher morbidity and mortality in LMICs is not a reflection of their own capacities as practitioners. Rather, it is likely because of weak public health systems, which are a consequence of weak institutions and low resources in LMICS. 

To prevent pandemics, public health systems need to build the capacity for active surveillance for early detection of cases and to mobilize their health care coordination capacity, which would enable rapid actions. The idea is to contain the virus before it spreads — a battle we have lost in many higher-income countries in North America and Europe.  

Nobody yet knows exactly how many COVID deaths will be visited upon LMICs, but there is little doubt that many were preventable.  

Although the World Health Organization (WHO) has established pandemic preparedness plans for all countries, LMICs especially are not about to implement those plans with low resources. Implementing those plans and building preparedness before a pandemic starts may have prevented many deaths. 

Health care workers from LMICs remind us that we shouldn’t speak only about COVID-19, without acknowledging other types of preventable deaths. The WHO estimates that globally there are between 250,000 and 500,000 annual influenza deaths, over 400,000 deaths from malaria, and 1.5 million deaths from tuberculosis. Moreover, developing countries also are in the midst of a global non-communicable diseases epidemic; people are dying from diabetes and heart disease.

The key to addressing all these preventable deadly conditions is a strengthened public health system in LMICs. Of course, each of these diseases demands different treatments and different dimensions of health care systems. But the only way to provide cost-effective interventions on a large scale is through strong public health systems.

Thus, the hope in LMICs for mitigation of the COVID-19 pandemic — and prevention of future pandemics and other preventable diseases — lies in smart humanitarian aid for public health strengthening and disease control. Recently, to fight COVID in LMICs, the United Nations launched a $2 billion fund and then called for a stunning 10 percent of global GDP, while the United States pledged $1.3 billion. 

We should recall the example of President George W. Bush establishing the President’s Emergency Plan For AIDS Relief (PEPFAR) in 2003. Since its inception, PEPFAR has invested $90 billion, helped contain the global HIV epidemic, especially in Africa, and saved over 17 million lives. Many of the countries where PEPFAR remains are among the most vulnerable to COVID-19, so it is possible to leverage existing global health assets. 

Pandemics are likely to occur more and with greater intensity in part because of travel and interconnectivity of population centers, as well as climate change. Ours is a world of nearly 4.6 billion airline passengers per year, including international flights that connect our countries and make global human-to-human viral transmission a certainty.  

Even if the U.S. and other high-income countries manage to control the COVID-19 outbreak, if coronavirus rages on in LMICs it will again easily spread across borders and lead to repeated, and more deadly, outbreaks, as was the case with the 1918 Spanish flu. 

From a cost-effectiveness perspective, world leaders should ask: What investment would be needed to adequately protect the world against COVID-19 and another pandemic? No doubt it’s a tiny percentage of the loss of economic activity and the ensuing burden on governments throughout the world.   

Lastly, while strengthening public health systems, don’t focus just on one disease, but instead on many, communicable and non-communicable. This will represent the greatest return on investment. 

Health care workers are pleading for us not to accept mass deaths from COVID-19 and other preventable diseases in LMICs as the “new normal.” Let’s stand with them and press our leaders to invest in strengthening public health systems and disease prevention in the world’s poorest countries.  

Stevan Weine, M.D., a professor of psychiatry, is director of global medicine and director of the Center for Global Health at the University of Illinois, Chicago. 

Bellur Prabhakar, a professor of microbiology and immunology, is senior associate dean for research in the College of Medicine at the University of Illinois, Chicago.