The fight against coronavirus will not be won until every country in the world can control the disease. But not every country has the same ability to protect people.
For low-income countries that struggle with weak health systems, large populations of impoverished people and crowded megacities, "there needs to be a very major adaptation" to the established measures we've been using to fight COVID-19, says Dr. Wafaa El-Sadr, an epidemiologist and director of ICAP, a global health organization at Columbia University.
The COVID-19 playbook that wealthy nations in Europe, Asia and North America have come to know — stay home as much as possible, keep a six foot distance from others, wash hands often — will be nearly impossible to follow in much of the developing world.
"I think they're trying, but it's not easy," El-Sadr says. "Ministries of health are working, partnering with international organizations to try to innovate — and hopefully, if the innovation works, it can be scaled up."
Here are some of the solutions now being tried.
Fly in tons of medical gear
Problem: Countries in the developing world face massive shortages of medical gear like personal protective equipment, says Avril Benoit, executive director of Doctors Without Borders. And the cutback in commercial flights has made it difficult to bring in equipment.
Solution: The U.N. has launched what it's calling "solidarity flights" – hiring charter planes to airlift millions of face masks, face shields, goggles, gloves, gowns and other supplies. On April 14, the U.N. dispatched an Ethiopian Airlines charter flight from Addis Ababa full of COVID-19 gear to transport to countries in need.
"This is by far the largest single shipment of supplies since the start of the pandemic, and we will ensure that people living in countries with some of the weakest health systems are able to get tested and treated," said Dr. Ahmed Al-Mandhari, WHO regional director for the Eastern Mediterranean in a statement.
Assessment: "In the short run, a program like this is fine so long as we're dealing with an acute event," says El-Sadr. "Without [supplies like] PPE, you're at risk of losing your scarce and precious health workforce — and you want to protect them at any cost."
But hiring chartered flights to deliver any kind of aid – instead of commercial flights – is expensive, says Manuel Fontaine, director of emergency programs at UNICEF. The U.N. is calling on donors to provide $350 million to continue this program; so far, it has received $84 million.
Create safe havens for the sick and elderly
Problem: How do you protect the most vulnerable individuals in crowded cities and refugee camps? And how do you keep infected individuals from spreading the disease?
Solution: Health authorities are trying out a somewhat controversial strategy: separating the sick and those at high risk, moving them from the homes where they might live alone or with an extended family into vacant homes or taking over facilities previously used for other purposes, such as learning centers. The people being targeted include the elderly and those with preexisting health conditions that make them susceptible to COVID-19 — as well as the homeless.
The strategy has been cited by several health researchers as a practical way to control the spread of disease in densely packed communities. Francesco Checchi of the London School of Tropical Health and Medicine wrote a paper on the subject, and Dr. Paul Spiegel of Johns Hopkins University, in another paper, recommended this as a potential solution in refugee settings.
Assessment: In his paper, Spiegel warns that the strategy of isolating these groups are "novel and untested." And thus far, in parts of the developing world where the strategy has been rolled out, it has had mixed results.
Shah Dedar, an aid worker with the humanitarian group HelpAge, says that religious and community leaders among the Rohingya refugees in Bangladesh don't like the idea of taking the sick or the elderly from the families who might care for them. But "elderly men and women with chronic diseases [who lived alone] were very much keen to the idea and appreciated the initiative," says Dedar.
While HelpAge was able convince local Rohingya leaders to give it a try, Spiegel of Johns Hopkins University says that this may not always be possible. In the case of a severe outbreak, aid workers may have to forcibly separate populations, whether the community approves or not. And he warns that this shielding measure is no guarantee it will keep the virus at bay — it could spread within these facilities, as has happened at some nursing homes in the U.S.
And in Cape Town, South Africa, conditions in a homeless "camp" set up by the government have prompted complaints from the residents about close contact and lack of sanitation — and a call from Doctors Without Borders to shut it down.
Get out of town
Problem: Some citizens are afraid of staying in big cities where social distancing is hard to maintain and outbreaks are more likely to spread.
Solution: Those who have family in ancestral homelands are traveling back to stay in these rural environments – it's happened in countries ranging from Bangladesh to Italy.
Assessment: Both government officials and citizens have criticized this exodus, saying that it puts elderly people in those rural environments at risk if the city dwellers might be contagious yet asymptomatic or presymptomatic.
The other downside of fleeing to these more remote areas, says El-Sadr, is that "health care services are less likely to be available."
That said, El-Sadr notes that this kind of population shift can be a good strategy in an area where transmission within a community has not yet occurred but is deemed likely. This could be a "way that people can have more of an ability to survive, to make a living, get social support [if they are sick], get more access to food, where they can socially distance more readily."
Get the police involved
Problem: Social distancing is hard to enforce in densely populated low-income countries.
Solution: Many governments around the world have turned to the police to ensure that people stay home — and hand out punishments to those who aren't following the lockdown rules. In India, for example, people who violate the lockdown could face up to a year in prison. Others in the country have faced unusual punishments, such as writing "I am very sorry" 500 times, according to an NPR report.
Assessment: Unfortunately, there have been reports of officers using physical violence to keep people in their homes in several countries, including India, Bangladesh and the Philippines. In Kenya, the violence has resulted in public outcry, with citizens calling for more civility from its police force. "This is no way to fight a coronavirus epidemic," tweeted a Kenya-based journalist.
Reinvent factories so they can make medical equipment
Problem: More supplies to fight COVID-19 are needed.
Solution: Get factories to switch gears and respond to the coronavirus.Kenya's textile industry has pivoted to making masks and protective equipment. The Kitui County Textile Center (KICOTEC) has shifted from sewing chef's whites and school uniforms to turning out face masks and scrubs for healthcare workers. Kenya's state-owned oil company is now making hand sanitizer, which it says it is distributing for free.
In South Africa, the state-owned missile manufacturer Denel, has been working to design and build ventilators, and to convert armored trucks into ambulances. The government has launched an initiative called the National Ventilator Project, which calls for companies to build 10,000 ventilators by the end of June, using locally available parts and materials.
Similar efforts are underway in Nigeria, where the government announced that they're working with car companies to manufacture locally-made ventilators.
In Kenya, KICOTEC turning out 30,000 surgical masks a day, according to Kenya's Ministry of Health. Kenya's petroleum company has produced more than 80,000 gallons so far, and plans to make at least 600,000 gallons more.
But WHO projects that countries will need millions of masks, goggles and other supplies to protect healthcare workers and citizens while mounting a response to COVID-19.
So local manufacturing can only partly fill the gap. But local authorities believe it is critical: "We're trying to build up local capacity to ensure that the critical facilities, the beds and ventilators, respirators could be made available within the country," says Adaeze Oreh, a senior official in Nigeria's Ministry of Health, "So we're not constrained by international travel restrictions, border closures and relying on imports."
Set up handwashing stations
Problem: Public health officials globally stress the importance of frequent hand-washing in the fight against COVID-19. In low- and middle-income countries, however, 35% of people lack regular access to soap and water, according to WHO.
"The health workers say we must wash our hands," said Zukwisa Qezo, a 47-year-old mother of two who lives in the Cape Town township to NPR. "But with what?! The city must bring us soap."
Solution: To improve the ability for people to clean their hands, WHO advises that hand hygiene stations — either with soap and water or with alcohol-based hand sanitizer — to be placed at the entrances of buildings, and in transport hubs such as bus and train stations. The system can be as simple as two buckets — one filled with chlorinated water, and one to catch the wastewater.
Assessment: Public hand-washing stations, which were effective in the fight against Ebola, are being resurrected in countries such as Liberia and Sierra Leone, NPR reports. Doctors Without Borders reports that their volunteers are setting up hand washing points in many of the settings they operate in, including migrant camps in Nigeria and health facilities in Mozambique.