“Social support, which is about ensuring that people have the material resources and necessities required to be able to ensure effective care is delivered, is a critical piece that has been under-invested in and focused on Europe in the US and the response to the pandemic.” – Katie Bollbach, director Of US Public Health Accompaniment Unit, PIH USA

New York City, USA – With no approved vaccines and cures on the market for COVID-19, countries everywhere have retreated back to the fundamental public health measures to control the pandemic – test, track, and isolate cases.

And many global health organizations, such as global health NGO, Partners In Health, that have helped manage outbreaks in low resource settings for years, could see the impending signs of an outbreak spiraling out of control in the rich countries that were first hit by the pandemic. It was the first time that these organizations had to set up emergency responses in the countries of their headquarters.

The steady disinvestment in local public health systems in rich countries like the United States, even before the pandemic, had left local authorities woefully underprepared for rapidly responding to an emerging infection.

“For those of us Americans who spend most of our career working outside of the US… it’s been incredibly eye-opening and humbling to see how COVID has absolutely overwhelmed the capacity of our system here in the US,” said Bollbach. “We simply have a deeply fragmented, underfunded, and misaligned health system not really focused on prevention and public health and primary care, but rather on a specific slice of for-profit, secondary and hospital based care.

“And so we’ve seen the result of that in terms of our inability to control the epidemic here in the US.

And from the get-go, it became clear that the same barriers to care that patients faced in low resource settings were replicated in the high income countries. In Massachusetts USA, where PIH first began to engage in the COVID-19 response, it quickly became clear that not everyone had the resources to safely isolate at home.

“We know that it’s simply insufficient to call someone and say, you’ve tested positive for COVID, please stay home for two weeks. Not everybody will be able to do that,” said Bollbach. “People’s ability to stay at home and isolate is linked to their material resources and the broader social determinants of health, such as their household dynamics.”

A panel of experts from PIH discussed local pandemic responses in the United States, Mexico, and Lesotho at a webinar discussing “Why Local Public Health Systems Play A Critical Role in Controlling the Spread of COVID-19” on Wednesday. The webinar is the fourth and final installment in the Global Pandemics in an Unequal World series hosted by the New School, Health Policy Watch, and the Independent Panel on Global Governance for Health. Panelists focused on each individual countries’ struggles, and noted what the various countries could learn from each other.

Implementing Social Support In Massachusetts, USA

The large majority of people who get infected with COVID-19 will not require hospitalization, says Bollbach. Approximately 80% of cases will be moderate, mild, or asymptomatic, and people can stay at home to recover.

“We’ve been really focused on ensuring deeper investment in staffing and resourcing at a local community level to facilitate the coordination of care and safe isolation,”  said Bollbach. 

The Massachusetts contact tracing team, for example, refers patients to care resource coordinators, who work with the patient to help identify needs. 

“This ensures that there is referral and follow-up, to get home delivery of groceries, to get cash to make up for lost wages… We’ve found in our work in Massachusetts that 20% of cases require some form of care, referral, or social support,” said Bollbach. 

The care resource coordinator model has been implemented in contact tracing teams in other major US cities as well, including New York City, the original epicentre of the US’ COVID-19 epidemic.

Big Cities Have Resources, But What About Rural Regions? – A Case From Mexico

Mexico City has also instituted a social support program, in which those who are diagnosed with COVID-19 can receive a care package that contains food, medicine, and extra cash to help ease the burden of lost wages.

But in poorer, rural regions of Mexico, such as Chiapas where PIH’s Mexico team works, the state has little money and resources to help support those that require safe isolation, said Daniel Bernal, sub-regional coordinator for Companeros En Salud Mexico.

“Here, 85% of people live below the poverty line,” said Bernal. “In contrast with Mexico City, we in Chiapas are only doing 0.6 tests per 1000 people per day, less than 3% of the suspect cases and 0% of contacts have been tested, there’s no quarantine for contacts, and there is no money for state social support.

This is why local responses are critical. Communities know and care for themselves, and despite having limited resources, so community engagement is the best option…Communities decide and reinforce social distancing norms.”

In the beginning, Bernal noted that communities did not even want to get tested for COVID-19. But having a strong community engagement strategy, especially in engaging with local leaders, has been important in changing the public perception around testing.

“I think the key piece is the community health workers that have been working with us,” said Bernal. “Some of them have been with us for five years now. And the fact that the information comes from someone in the community that works with [a trusted] organization, that’s been really important.”

But ultimately, more “investment [is needed] to shape the response,” said Bernal. “The thing that they did in China was to set up spaces for isolation. And this is the ideal response, and is something that we are trying to fight to have in Mexico.

“The fact that you don’t have the resources [does not mean] that you can just say, ‘well, it’s not going to happen and we won’t do anything.'”

Building On Existing Local Capacities In The COVID-19 Response in Lesotho

In Lesotho, where PIH has been involved in strengthening the country’s response to HIV/AIDS since 2006, the organization was well positioned to build on the existing HIV/AIDS infrastructure to help augment the COVID-19 response, said Melino Ndayizigiye, acting director of PIH Lesotho.

Over the years, PIH has helped support the training, deployment, and retainment of more staff at rural clinics and health centres, built up patient referral systems, and helped procure medical equipment and supplies for clinics.

But when COVID-19 hit, the country, which has one of the lowest life expectancies in the world had been struggling with multiple heath crises such as tuberculosis and HIV/AIDS, said Ndayizigiye. The COVID-19 response had to also consider patients co-infected with the novel coronavirus and disease like tuberculosis or HIV.

“We have also created a treatment center for multidrug resistant tuberculosis patients who are also co infected with COVID-19. We empowered staff and send them guidelines on managing medical conditions co-existent with COVID-19. And we have integrated medical health care and psychological insights, psychological support services,” said Ndayizigiye.

But ultimately, the system is currently still dependent on outside support.

On average, in PIH supported clinics, some 20 staff are paid by the organization, which receives funding from government grants from high-income countries, large private foundations, and private philanthropy. And the country, which is landlocked within South Africa, is still dependent on South Africa to supply medical oxygen, a key tool required for the treatment of more severe COVID-19 cases.

“We are establishing an oxygen plant that will produce oxygen for COVID-19, and for patients [with other diseases] who might need it across the country,” said Ndayizigiye. “We are thinking beyond COVID-19, because what we have seen what the country lacks.”

Image Credits: Partners in Health.