Suspending support for WHO: A decision that will live in infamy?

President Trump’s decision to halt aid to the World Health Organization (WHO), if it is not overturned soon, will live in infamy. In late April, while the president was floating the absurd notion that injecting disinfectant might help fight the coronavirus, over 1,000 organizations and individuals signed a letter asking the White House to restore aid to the WHO, calling it “the only organization with the technical capacity and global mandate to support the public health response of all countries during this critical time.” That is particularly true in Africa.

Africa’s nightmare is just beginning. Almost certainly COVID-19 will lead to widespread illness and death on the continent. Unless more is done now to mitigate the threat, the coronavirus will become deeply entrenched, Africa will become the new epicenter of the pandemic, the death toll will soar and the fight against covid-19 will be measured in years, not months, even if a vaccine becomes available.

Nearly everyone worldwide is at risk from the pandemic, but Africa is more vulnerable, especially the billion people living in sub-Saharan Africa, because of poor health, substandard living conditions, weak health systems, food insecurity and pre-existing illnesses that increase the risk of illness and death from coronavirus. In sub-Saharan Africa 26 million people are infected with HIV, and 200 million suffer a malaria infection each year. This is compounded by malnutrition affecting 23 percent of the population, making sub-Saharan Africa the region with the highest prevalence of undernourishment in the world.

On the other hand, the case fatality rate in Africa may be lower than in the U.S. or Italy, because the population is relatively young. Sixty percent of Africa’s population is 24 or younger. The median age is 19.7. But Africa’s age demographics notwithstanding, living conditions in sub-Saharan Africa still make the region highly susceptible to rapid, unchecked spread of COVID-19.

The U.S., Italy, France, and other wealthy countries have suffered from inadequate supplies of test kits and personal protective equipment. Those problems will be much worse for sub-Saharan Africa. Developed countries’ hospitals have sometimes been overwhelmed with the COVID-19 caseload. But this will be much worse in sub-Saharan countries, where there are typically 0.3 to 1.5 hospital beds per 1,000 population versus 2.9 in the U.S.

Beyond inadequate health infrastructure, prevention and treatment will also be hampered by extreme poverty, weak governments and institutions, and lack of basic services. Those problems are in turn exacerbated by political instability, conflict and terrorism, and also by large flows of refugees and migrants.

Of Africa’s 1.3 billion people, nearly 500 million live in densely crowded urban areas. 7.4 million are refugees and 17.8 million more are internally displaced. Sub-Saharan Africa has 4.4 million refugees. It’s impossible to fully implement control measures such as physical distancing, frequent hand washing, and sanitizing living spaces in slums or refugee camps. Across the continent, isolating people who are ill and minimizing large gatherings of people at markets, sporting events and schools will be difficult. Social interactions are crucial to the informal economy, the source of 60 to 80 percent of employment. Sheltering at home requirements will exacerbate poverty and jeopardize food security for millions of people.

To prevent spread of the virus in Africa’s crowded urban areas, people with mild or asymptomatic cases in Africa will require isolation and quarantine. Those exposed to them will need to be tracked, identified, tested, monitored and if necessary isolated and cared for. Large cadres of medical and community health workers will be needed, but there aren’t enough to go around.

Health care workers shortages are extreme. In sub-Saharan African countries there are only 0.1 to 0.3 physicians per 1,000 population­­ — the corresponding ratio in the U.S. is 2.6. There are fewer than 1 nurse or midwife per 1,000 population; in the U.S. it is 8.5.

These shortages are largely a consequence of chronic underinvestment in human capital, which is getting worse as the population grows. Sub-Saharan Africa’s population is projected to grow from a mid-2019 population of 1.07 billion to 1.58 billion in 2035, and 2.15 billion in 2050. Growth will further strain health systems and exacerbate shortages of health care workers. Meanwhile, worker shortages in other parts of the world affected by COVID-19 also limit the potential to bring reinforcements to work in Africa.

Overall, Africa is the continent most vulnerable to the COVID-19 pandemic. The WHO’s Infectious Disease Vulnerability Index (IDVI) measures a country’s capacity to detect and respond to outbreaks of infectious diseases, scoring them from zero to 100. Twenty-two of the lowest scoring, most vulnerable countries are in Africa. Nigeria, the most populous African country, scored 27. Ethiopia, the second most populous, scored 38. Sudan, Angola, Tanzania, Ghana, and Kenya all have scores of less than 46.

Prior experience in fighting Ebola outbreaks may help some African countries, but in general COVID-19 will spread far more widely and rapidly in Africa than elsewhere. 

Like the rest of the world, Africa will benefit from development and dissemination of better treatment methods for COVID-19, and widespread infection may eventually lead to herd immunity. But ending the pandemic will require a new vaccine and mass immunization. This will take a year or much longer.

Meanwhile, to avoid a humanitarian disaster of continental proportions, emergency assistance from the world community, including WHO, is needed now. Long-term, major investments will be required to improve Africa’s health systems, as well as sharply increased investment in family planning and girls’ education to slow Africa’s population growth.

We need aggressive and massive international collective action now, for Africa’s sake and our own. In a pandemic, no one is safe, until everyone is safe. U.S. suspension of WHO funding is self-defeating.  It will limit the resources WHO can devote to fighting COVID-19 in Africa. And for that, we may all pay a heavy price.

Dr. J. Joseph Speidel is a Professor Emeritus, at the University of California, San Francisco, School of Medicine. He is currently serving as a non-resident senior fellow at the Population Institute.