The 2019-nCoV pandemic in the global south: A Tsunami ahead

During the coronavirus disease 2019 (COVID-19) pandemic, high-income countries have faced shortages of medical supplies, personal protective equipment (PPE), ICU beds and ventilators [1Ranney M.L. Griffeth V. Jha A.K. Critical supply shortages — the need for ventilators and personal protective equipment during the COVID-19 pandemic.N Engl J Med. 2020; (10.1056/NEJMp2006141)Crossref PubMed Scopus (1386) Google Scholar]. In this unexpected scenario, physicians working in the world's richest nations have been left to decide who will receive mechanical ventilation and, ultimately, who lives and who dies. Most countries in the Global South have yet to experience a significant wave of COVID-19, but are predicted to follow a similar trajectory as the Global North. The recent decision of President Donald Trump to withdraw US financial support for the World Health Organization (WHO) will deeply affect its ability to provide critical humanitarian aid to countries with the weakest health systems in the world [2The New York Times. Trump halts world health organization funding amid coronavirus pandemic. Available at: https://www.nytimes.com/video/us/politics/100000007088432/trump-world-health-organization-coronavirus.html, 2020. Accessed May 8, 2020.Google Scholar]. The US decision may lead other nations to withdraw support and undermine WHO's efforts amidst the COVID-19 pandemic. This could lead to millions of additional preventable deaths directly and indirectly related to COVID-19 [3The Guardian. “US scuppers G20 coronavirus statement on strengthening WHO” Available at: https://www.theguardian.com/world/2020/apr/20/us-scuppers-g20-coronavirus-statement-on-strengthening-who, 2020. Acessed May 8, 2020.Google Scholar]. In contrast to earlier pandemics, in our globalized world where nations are closely interconnected, ripple effects of new waves of COVID-19 could impact not only the Global South, but worldwide. The unprecedented impact of the COVID-19 pandemic has also influenced regional collaborations. One shocking example is the redirection of shipments of ventilators, PPE and medical supplies from resource-limited settings to richer countries [4Reuters. “U.S. coronavirus supply spree sparks outrage among allies” Available at: https://www.reuters.com/article/us-health-coronavirus-masks/u-s-coronavirus-supply-spree-sparks-outrage-among-allies-idUSKBN21L253, 2020. Accessed May 8, 2020.Google Scholar]. Benefits of multilateralism might appear unidirectional from Global North to South, but this is a superficial assumption. The Ebola outbreaks and the HIV/AIDS pandemic, for example, demonstrated the importance of scientific collaborations between scientists from the Global South and North to respond to these global health threats [5Erondu N. & Agogo E.What factors will decide the fate of the global south in coronavirus pandemic?Available at https://theGlobalobservatory.org/2020/03/what-factors-will-decide-fate-Global-south-coronavirus-pandemic/, 2020. Accessed May 8, 2020.Google Scholar]. The response to the COVID-19 pandemic is deeply influenced by local, regional, national and global policies and political decisions. Some nations who adopted early containment measures, (e.g. school closures, widespread diagnostic testing) such as Germany experienced lower COVID-19 incidence and mortality [6Nussbaumer-Streit B. Mayr V. Dobrescu A.I. et al.Quarantine alone or in combination with other public health measures to control COVID-19: a rapid review.Cochrane Database Syst Rev. 2020; 4CD013574PubMed Google Scholar]. However, those strategies might not be feasible or could have unintended consequences in the Global South. For example, India declared the biggest nationwide lockdown in the world, affecting 1.3 billion people and unleashing chaos across the country [7Menezes V. “India's leaders have panicked. Now the millions who power the country are suffering” Available at: https://www.theguardian.com/commentisfree/2020/apr/08/india-leaders-coronavirus-lockdown, 2020. Acessed May 8, 2020.Google Scholar]. The total shutdown of public transportation forced millions into makeshift shelters or open fields, where they rely on public toilets and food handouts, making key strategies such as hand hygiene and social distancing impossible [7Menezes V. “India's leaders have panicked. Now the millions who power the country are suffering” Available at: https://www.theguardian.com/commentisfree/2020/apr/08/india-leaders-coronavirus-lockdown, 2020. Acessed May 8, 2020.Google Scholar]. In Brazil, more than 14 million people live in crowded slums lacking basic sanitation where tuberculosis and Zika have flourished. Brazilian President Jair Bolsonaro, has downplayed COVID-19 as a ‘little flu’ and recently fired his Minister of Health after disagreeing about the need to adopt social distancing. The country has the highest number of COVID-19 cases and deaths in Latin America and has yet to declare a national lockdown [8Darlington S. & Kottasová I. “Brazil president Bolsonaro replaces health minister” Available at: https://www.cnn.com/2020/04/16/americas/brazil-health-minister-fired-intl/index.html, 2020. Accessed May 8, 2020.Google Scholar]. According to the International Rescue Committee [9International Rescue Committee. COVID-19 in humanitarian crises: a double emergency. Available at: https://www.rescue.org/sites/default/files/document/4693/covid-19-doubleemergency-april2020.pdf, 2020. Acessed May 8, 2020.Google Scholar], South Sudan only has four ventilators and 24 ICU beds for 12 million inhabitants. Similar scenarios exist in Northeast Syria (11 ventilators), Sierra Leone (13 ventilators), among others. In Venezuela, 90% of hospitals lack critical supplies and in Yemen, 18 million people do not have access to proper hygiene, water and sanitation [9International Rescue Committee. COVID-19 in humanitarian crises: a double emergency. Available at: https://www.rescue.org/sites/default/files/document/4693/covid-19-doubleemergency-april2020.pdf, 2020. Acessed May 8, 2020.Google Scholar]. In these fragile and conflict-affected countries, there is not enough resources to increase the availability of hospitals, healthcare professionals, ICU beds or ventilators in time to respond to COVID-19. These regions need assistance to urgently adopt public health measures to strengthen case identification, contact tracing, isolation, quarantine, social distancing, hand hygiene and PPE. The Global South needs humanitarian support now. But the Global North can (and should) learn from successful public health strategies adopted by the most vulnerable countries in the world. Liberia and Sierra Leone, for example, already experienced quarantine and school closures for extended periods [10Nyenswah T.G. Kateh F. Bawo L. et al.Ebola and its control in Liberia, 2014-2015.Emerg Infect Dis. 2016; 22: 169-177Crossref PubMed Scopus (47) Google Scholar]. Brazil controlled a recent Zika epidemic and offers free/universal prevention and treatment to HIV/AIDS. Amidst the COVID-19 pandemic, global collaboration is key and should include data sharing, equitable distribution of resources, novel treatments and vaccines. Successful experiences and lessons learned from previous public health responses to SARS, H1N1, Ebola, HIV/AIDS should be amplified and adapted to the COVID-19 pandemic [5Erondu N. & Agogo E.What factors will decide the fate of the global south in coronavirus pandemic?Available at https://theGlobalobservatory.org/2020/03/what-factors-will-decide-fate-Global-south-coronavirus-pandemic/, 2020. Accessed May 8, 2020.Google Scholar]. Responses should be coordinated to achieve a sustainable aim: to control the pandemic regionally, nationally and globally.20 To fight this pandemic (and future global threats), nations should adopt strategies and approaches emphasizing that “We are all in this together.” The US should renew its support to WHO: the pandemic will not be over anywhere until it is over everywhere. MM conceived, drafted the manuscript and coordinated subsequent edits and revisions. AWR, NAH and SAS participated in drafting the manuscript and its finalization. All authors have read and approved the final manuscript. There was no funding source for this study.

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