As the world struggles with the rapidly evolving pandemic of novel coronavirus disease
(COVID-19), evidence and experience suggest that low-income and marginalized communities
in our global society will bear the biggest impact. We know this because, with our
colleagues in Boston, Haiti, Uganda, and Sierra Leone, we have worked in under-resourced,
overstretched, and overwhelmed health systems for our whole careers. We know we will
see the devastating impact of this pandemic on those who are already marginalized;
COVID-19 will amplify existing inequities, and we must act swiftly to leave no one
behind.
Diagnostics, pharmaceutical interventions, and public health solutions for other pandemic
diseases such as tuberculosis, HIV infection, and cholera have never fully “trickled
down” to marginalized or impoverished communities. That is why, for example, HIV infection
rates remain alarmingly high among adolescent girls in South Africa,
1
and transgender people and communities of color in the United States,
2
and why tuberculosis still remains a major public health concern despite the advent
of effective therapy for drug-sensitive disease almost 50 years ago.
3
As the world races to find an effective antiviral against severe acute respiratory
syndrome coronavirus-2, as well as a vaccine, will these become sovereign commodities
of the global North? We see no reason why injustices of the past will not be repeated
just because the pathogen is novel. Often, widespread access to lifesaving therapeutics—like
treatment for HIV infection—has only been made possible for marginalized groups through
hard-fought activism. But activism alone is not enough—in 2019, the U.S. government
declined influenza vaccinations to detainees of the Customs and Border Protection
agency despite documented deaths of children in these detention facilities from influenza
and protests by medical professionals.
4
As the incidence of COVID-19 escalates in low-income countries, we have five specific
concerns as global health faculty at large U.S. teaching hospitals. First, it is well
documented that structural and institutional racism, and the marginalization of migrant
communities, perpetuate differential outcomes in health. Poor or otherwise marginalized
communities, including communities of color, have been systematically left behind
as biomedical progress advances. Existing health disparities, such as disparities
in the prevalence of pulmonary disease, highlight worrisome risk factors for increased
incidence of COVID-19. Asthma rates are higher among U.S. black and native American
children than U.S. white children, and asthma is most prevalent in the poorest socioeconomic
groups.
5
Tobacco companies, after spending decades enticing the use of their products in low-resourced
settings, have acquired 1.1 billion customers who smoke, of whom 80% reside in low-
and middle-income countries.
6
Long-term consequences of smoking, such as chronic lung disease, have already been
linked to worse COVID-19 outcomes. As of this date, in mid-April 2020, most confirmed
cases of COVID-19 have been in Europe, East Asia, and the United States, places where
noncommunicable diseases predominate the health landscape. We know very little about
how malnutrition, tuberculosis, HIV infection, and soil-transmitted helminth infections
will impact the disease course of COVID-19, but these could have major implications
for low-resourced communities in which the prevalence of these diseases is high.
Second, although almost every health system’s capacity would be surpassed by an unmitigated
surge in COVID-19 cases, fragile health systems in low-income settings struggle daily
to diagnose and treat even moderately unwell people because of chronic shortages of
trained staff, effective therapeutics, diagnostics, and built infrastructure. Global
inequity in maternal mortality, under-5 diarrheal mortality, and deaths from pneumonia
all highlight this fact. Already, around the world, there are countless unnecessary
deaths on a daily basis—“senseless deaths” that never needed to happen because we
know what to do. We have just failed to deliver.
Material deprivations in the built health environment are pervasive, and personal
protective equipment to care for patients with transmissible diseases are already
in desperately low supply in many countries. Laboratory capacity is often limited
by a lack of staff and supplies, and laboratories are frequently centralized in urban
regions, leaving rural places without access. Low testing rates for COVID-19 in countries
such as Haiti, Yemen, and Central African Republic emphasize already how challenging
it will be to even understand the pandemic without accessible diagnostics; never mind
trace and isolate those people with infection for effective control.
Although the year 2020 opened with a celebration of the international year of the
nurse and midwife, the WHO’s most recent data estimated a global deficit of 17.4 million
health workers, mainly in Africa and Southeast Asia.
7
Although our own hospitals in Boston scramble to create rosters with three or four
layers of staffing backup to cope with forecasted numbers of sick or exposed staff
and patient flow, how will communities with a drastically insufficient health workforce
at baseline cope?
Third, in many circumstances, it is impossible to quarantine at home or to self-isolate.
Homeless people, displaced populations, and prisoners cannot choose to be physically
distant from others. Haiti, where we have worked for almost two decades, is one of
the most densely populated countries in the Latin America Caribbean region, with whole
families often living in humble one- or two-room abodes. Social distancing, one key
part of aggressive containment strategies, is not feasible for large swathes of the
world, and advisories to stay at home ignore the realities of some of the 820 million
food insecure people in the world, for whom the day’s food is acquired only at the
end of the day’s work. Food insecurity has a detrimental impact on health which is
why, for example, in the midst of a major epidemic in Haiti in 2012, cholera was almost
twice as deadly for families that were severely food insecure than for families with
steady access to food.
8
Fourth, water insecurity and lack of access to safe sanitation and hygiene will undermine
a basic pillar of COVID-19 prevention in many parts of the world. Twenty-nine percent
of the global population lacks safely managed drinking water, and three billion people
do not have access to soap or water for handwashing at home.
9
The United States offers no exception, as the prevalence of exposure to hookworm in
a rural Alabama community and the failure to realize the right to clean water in Flint,
Michigan, both demonstrate.
10,11
Fifth, although the direct impact of COVID-19 is self-evident, the indirect impact
of the pandemic on other health indicators may be less visible. Fragile health systems
that are already stretched have little to no elasticity in supply and are at risk
for the biggest impacts of these indirect effects. The 2014 Ebola virus disease epidemic
in West Africa, for example, resulted in more than 4,000 maternal deaths, 6,700 infant
mortalities, and approximately 3.5 million more cases of untreated malaria because
the health system effort was, by necessity, redirected to the viral epidemic response.
12
What does global health equity mean in a pandemic of such magnitude as COVID-19? It
means we must take a proactive approach, addressing disparities and injustice from
the start—both in how we approach scientific discovery and in how we deliver interventions.
Scientists, practitioners, and community leaders in low-resource communities have
innovations, hypotheses, and proposed solutions to the COVID-19 pandemic. The global
public health elite must have the humility to include these as part of collective
action. We must commit, as a global community, to ensuring that when pharmaceutical
interventions are proven, they will be accessible to all, not only those who can afford
to pay. We need COVID-19 incidence and mortality data that are disaggregated by gender,
race, and location. We need radical social investments to support the most impoverished,
and we must decongest prisons and release detained asylum seekers to prevent unnecessary
deaths. Multilateral investment in health systems strengthening as a fundamental principle
of global health equity has never been more important than now. With an ambitious
belief in what it is possible to do for the poorest communities, we must commit to
global health equity, leaving no one behind.