This is a departure from our normal emphasis, but COVID-19 in developing countries is an important yet often overlooked issue.  Here’s a guess post from a colleague, Dr.  Philip Mshelbwala, who’s from Nigeria but currently studying in Australia:

The challenges of combating novel coronavirus COVID-19 in Developing World: The need for a workable strategy

Philip Mshelbwala DVM Msc

As cases of Covid-19 continue to spike globally and receive widespread attention in developed countries with good health care systems, less is discussed about developing countries with poorer healthcare and public health systems. In Nigeria, the most populous country in Africa with nearly 200 million population, the index cases was on Feb 27, 2020 in Lagos South West. As of mid-April, 627 cases had been reported in 19 states plus the Federal Capital territory (FCT), with 21 deaths. Included amongst the death toll was the government’s Chief of Staff to the government. While these illness and death numbers are substantially lower than many other countries, the scope of the problem is not understood. Testing has been limited, with the Nigerian Centre for Disease Control (NCDC) reporting only 7153 tests as of April 20. In comparison, Australia, with a population ~9 times smaller, has reported >431,000 tests. Therefore, it is unclear whether COVID-19 cases are relatively limited in Nigeria or whether low numbers simply reflect limited testing. When there are ongoing struggles to maximize testing in high GDP countries with high laboratory and healthcare infrastructure, personnel and funding, the challenges to implementing large scale testing in countries with fewer resources, trained personnel and equipment are clear to see.

In addition to the direct health and economic impacts of COVID-19, the pandemic’s impacts confound various issues in developing countries, impacting efforts to improve healthcare, education and other social support systems. In Nigeria, the outbreak has coincided with a time when the Nigerian Academic Staff of Universities Union  (ASUU) has embarked on an effort to highlight and improve underfunding of healthcare and education, including the failure of the government to respect the earlier agreement and issues of non-payment of salaries. While most institutions in developed countries have since moved into virtual learning platforms, there are more profound challenges to maintaining effective social distancing in developing countries such as Nigeria because of the limited access of platforms and infrastructure to facilitate remote learning, working and healthcare. Therefore, the impacts on some of the most susceptible nations are compounded.

The initial response in Nigeria was driven by individual states that took actions to impose movement restrictions, before the federal government placed a total lockdown (except those on essential services) in hot spots states of Lagos, Ogun and the FCT. While the strategy of ‘stay at home’ has worked for developed countries like Australia, that has continued to see a decline in the number of new cases, it has come at a cost. These include substantial government support programs to keep people employed, facilitating supply chains and critical stores (e.g. grocery stores) and engagement of volunteers to help the high risk groups (e.g. elderly) maintain effective distancing. However, these strategies may not be feasible in a setting with a different sociocultural disparity and economic resources. When people cannot eat if they cannot work, and if they cannot secure food while isolating, effective responses are compromised. Increases in crime are of concern. Moreover, compliance has been low due to poor knowledge of the public health implications and poverty, with belief among some that the virus does not exist. Limitations in public health education and confidence in the public health system hamper effective communication and education, further impacting compliance. Some unfortunate instances of reckless attitudes of enforcement officers has further compounded situation, with at least 18 extrajudicial killings during enforcement efforts. While fear may facilitate compliance, it leads to further distrust and hesitancy to engage and access needed government programs. A combination of governmental inertia, inherent funding and infrastructure challenges, limitation in ground level public health abilities and fear or mistrust create a situation where widespread death from both the virus and secondary impacts such as hunger and lack of healthcare access for other problems could cause substantial impacts.

The list below outlines some efforts that are needed in Nigeria. Many are standard responses that are used everywhere. However, there may be greater challenges implementing these common practices, as well as the need for additional or different approaches.

  • Expanding testing capacity through recruitment of university diagnostic laboratories.
  • Recruitment and training of volunteers for contact tracing.
  • Supporting remote teaching by Universities and other educational facilities providing access to online classroom and meeting systems.
  • Maintaining essential government services while maintaining social distancing.
  • Restricting public group activities (e.g. weddings).
  • Identification and provision of food and essential items to those in need, engaging non-Government organizations when relevant.
  • Educate the public on proper use of homemade facemask and hand gloves, while allowing the use of N95 and surgical masks exclusively for frontline health workers, using local languages. This can be facilitated through the use of existing structures put in place by the World Health Organization (WHO) and other partner agencies that have been used for combating polio and other vaccine preventable diseases of children in the region.
  • Educate law enforcement officers on humane treatment of defaulters.
  • Ensure frontline healthcare workers have adequate personal protective equipment.
  • Engage the services of local manufacturers to produce affordable ventilators and invest in equipping underfunded healthcare centres and personnel to ensure that advanced life support such as ventilation can be properly performed.
  • Educate the public about the risks of COVID-19, the reason for control measures and the ways people can protect themselves.
  • Restriction of interstate travel to slow the rate of spread.
  • Invest in research for local solutions to the pandemic, especially on ways to boost  community knowledge.

The toll of COVID-19 on developing countries is not well understood and limitations in healthcare and surveillance mean the impacts in many areas may ultimately never be known. However, when the profound impacts on well funded areas such as New York are considered, the potential impact on underfunded and crowded developing regions, as well as remote and unsupported rural areas in the developing world should be enough to prompt intense local and international action to reduce the health and societal burdens of this pandemic.