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5 essential steps for action during COVID-19

Unheeded warnings

When the High-Level Panel on the Global Response to Health Crises delivered their final report to UN Secretary-General Ban Ki-moon in February 2016, it contained two chilling conclusions: not only was the “risk of major (global) health crises widely underestimated” but the “world’s preparedness and capacity to respond is woefully insufficient”.

Three months later at the World Humanitarian Summit, Ban Ki-moon urged global leaders to adopt new action, imperatives and direction. Innovation of systems, processes and practice was needed at unprecedented levels across the entire sector to deliver more effective and efficient humanitarian aid. Four years elapsed with much discussion and little action, until now, when the humanitarian sector faces a crisis of unparalleled complexity.

The sector must urgently develop a strategy and operational response without its greatest collective strength: the ability to mobilise, deploy and coordinate human resources. The reason is straightforward:

Every aid worker represents a threat to unknowingly initiate the transmission of a lethal virus into any community, devastating health systems and killing tens of thousands of people within months.

Leaders of all humanitarian organisations should be advancing sector-wide business strategies to drive the innovation of planning, processes and actions necessary to achieve one simple goal: to slow the spread of this infection (often referred as ‘flattening the curve’) when it inevitably arrives in the highest-risk communities. It’s critical to unite the whole sector and encourage organisations not specifically involved in health provision to understand their unique role in preventing the death of hundreds of thousands of people currently at greatest risk.

No short- or medium-term reprieve from mortality risk

Even when local outbreaks become temporarily restrained, the majority of the human population remains at risk, not only from the life-threatening virus but of spreading the infection to others. The virus will cut loose again, initiated by undetected infections, and will spark a second wave of local outbreaks and epidemics of disease.

Even assuming an efficacious vaccine is developed within 18 months, commencing the process of herd immunity will take years. It requires regulatory approval, government funding, and high rates of community uptake, which despite the risk, are no certainty. The profound tragedy of hundreds of recent measles deaths underpinned by anti-vaccination rhetoric is a case in point.

Yet the risk of transmission via humanitarian responses is not the only factor keeping leaders of humanitarian organisations awake at night. Case fatality rates of COVID-19 have been shown to increase as age-cohorts increase, however this calculation of mortality risk is from COVID-19 disease alone. In fragile states and low-income contexts, the severe impacts on health service delivery from an uncontrolled SARS-CoV-2 outbreak will cause an increase in non-related causes of death, such as maternal mortality.

At the onset of COVID-19, the world faced unprecedented humanitarian need: 70.8 million people forcibly displaced from their homes; global hunger, once in decline, had increased in the three consecutive years to 821 million people; more than 2 billion people lived without access to safe drinking water; and the funding gap between humanitarian assistance need and delivery was growing, with the gap in 2017 at US$10.3 billion. The world’s richest countries have already reduced aid relative to their income (GNI) and now face a greater burden of debt to manage domestic health and economic consequences of COVID-19. Even with the level of humanitarian aid funding (ODA) provided, extraordinarily the proportion of ODA invested in health and social protection have declined.

Five key actions must now form the foundation of every humanitarian response, irrespective of the mission objectives or its location, until such time communities can be protected with a vaccine.

1. Protecting local health care workers

The purpose of flattening the curve is to prevent the health system being overwhelmed, the lived experience of health care workers (HCWs) around the world, not only Italy, Spain and the US, illustrates this reality. Fragile health systems have no resource alternative and the protection of HCWs must be the highest priority for the humanitarian sector until a vaccine. Protection of HCWs is not merely achieved through personal protective measures (PPE), such as gloves, masks and hand sanitiser, but also providing the resources and knowledge to implement infection control practices. For example, assessing patients, testing symptomatic people, caring for sick, transporting critically ill, and managing the deceased. Humanitarian agencies must closely examine the failings and successes of protecting HCWs in past emergencies such as the Ebola virus disease outbreaks and the Syria conflict to collectively discover approaches which can successfully protect them.

2. Supporting early emergency health responses

Every health service has required assistance to organise and activate activities to slow the spread of infection. These activities include early case detection, investigation protocols, case management plans, testing strategies and especially health surveillance. This activity in itself represents a monumental challenge, considering basic health surveillance is particularly weak globally, with more than half of all global deaths currently not registered. The humanitarian sector must discover means to support fragile health systems achieve such activities as soon as the first case of infection is diagnosed or detected.

3. Maintaining supply chains

The impact of commodity flows to fragile nations and the potential disruption to supply of essential products and services, such as food and medicine, needs careful analysis. The effect of health service demand on supplies of routine medicines in high-income countries demonstrates why contingency planning for supply chains, especially for food and essential medical supplies within the humanitarian sector is essential. This includes PPE for staff, diagnostics, and basic medical equipment required for specialist COVID-19 clinics, mobile treatment and care facilities, and patient breathing support apparatus.

4. Support access to diagnostics and therapeutics and vaccines

In mid-March, WHO Director-General Tedros Adhanom Ghebreyesus emphasised to all governments that stopping the epidemic required knowing who was infected and to “test test test”. In low-income countries (LICs) however, access to diagnostic services are limited. Providing testing capability for SARS-CoV-2 in nations with fragile health services requires access to training, test kits and test protocols. Strategies to support access should be paramount across humanitarian agencies, because early detection is not possible without widespread testing capability. Similarly, fragile states require access to vaccines and treatment therapeutics once available, either as a preventative health strategy or for use prophylactically. Access and financing for the vaccine must be prioritised for communities with the highest risk of mortality.

5. Supporting local emergency response strategies to slow spread

Countries have adopted different strategies and approaches to delay or slow the rate of spread of the virus. Typically these involve some form of social distancing or reducing the number and frequency of close interactions between people. Humanitarian actors must create communication strategies to support community understanding of such measures, along with the impact of such policies. This is especially important for the poorest communities where the purchase of food, water and energy are a daily challenge.

If the humanitarian system attempts to respond to any event during this pandemic using historical constructs, we will cause more harm than good. Until a vaccine for SARS-Co-V-2 is manufactured and adopted globally, outbreaks and epidemics will continue, possibly seasonally along with Level 3 emergencies.

And yet the humanitarian system cannot confuse the need to act with the desire for the perfect response. As Dr Michael Ryan of WHO’s Health Emergencies programme warned, “Be fast, have no regrets. You must be the first mover. The virus will always get you if you don’t move quickly … If you need to be right before you move, you will never win.

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