While very low-income countries have experienced relatively low mortality rates from COVID-19, they can expect higher mortality caused by the knock-on effects of the pandemic on their fragile health systems, according to the Executive Director of the Global Fund to Fight AIDS, TB and Malaria.

Since the pandemic first overwhelmed health systems in early 2020, countries across the globe have reported a reduction in referrals and diagnoses for various diseases.

“It’s a perfect storm of concurrent social crises which are disrupting health interventions: programmes to fight diseases like HIV, tuberculosis (TB) and malaria,” Peter Sands, Executive Director of the Global Fund, said during a session of the  World Economic Forum in Davos today.

Last year, India, Indonesia, the Philippines — three high-burden countries for TB — reported a 25-30% drop in its case notifications. A Lancet study predicted a 25% reduction in antimalarial drug coverage in 2020 in malaria-endemic African countries, potentially doubling mortality.

And although the pandemic has affected health systems in low- and high-income countries alike, poorer countries with weaker health infrastructure, greater disease burdens, and generally worse access to COVID-19 treatments and vaccines will have the hardest time recovering.

“Particularly, the lowest income countries have very young populations. This kind of demographic means that the mortality rate from COVID is relatively low,” he said. In the poorest countries, the life expectancy is about 18 years lower than the richest.

But these countries could be more vulnerable to the “collateral damage” of the SARS-CoV-2 pandemic, rather than the direct impact of the virus. 

“You’re going to see relatively low mortality from COVID itself, and relatively high mortality from these knock-on consequences,” added Sands.

Diagnosis Deficit: Lower Diagnoses Globally

The COVID-19 pandemic risks shattering countless disease elimination targets, many of which have been set by the World Health Organization (WHO).

Diagnoses and interventions for communicable and non-communicable diseases (NCDs) have both been impacted in 2020, with COVID-19 and related lockdowns affecting patients’ ability to get access to treatment.

The World Hepatitis Alliance found that last year 94% of respondents in its 32-country survey had had their hepatitis services closed. In addition, half of respondents in lower- and middle-income countries (LMICs) could not get their medication, with respondents in India and Nigeria citing pandemic-related travel restrictions as the cause.

“The Task Force for Global Health and the World Hepatitis Alliance [have] all come up with the same figures,” said Charles Gore, Executive Director of the Medicines Patent Pool.

“Diagnosis and treatment are the key areas in [WHO’s] Global Strategy where the world is lacking,” he added. “And unfortunately, the hit is even bigger in LMICs.”

Where access to treatment for a given disease might have been reduced by 40-60% in a high-income country, “we’re talking 60-90% in LMICs”.

“There’s an estimate that a one-year hiatus in [a country’s] national programs from hepatitis elimination will lead to an extra 45,000 liver cancers and 72,000 deaths by 2030,” he said.

The reduction in access to treatments is similarly stark for NCDs.In the UK, lung cancer referrals in August 2020 were down by 26% from the previous year. During the April lockdown — when much of the Western world experienced its first COVID wave — referrals for lung cancer from doctors’ surgeries dropped by 72%.

“Even if they are referred, it’s very difficult to get patients through the system, and get respiratory symptoms investigated so they can start treatments quickly,” said Michelle Mitchell, chief executive of Cancer Research UK.

“This is a time of great worry for patients with lung cancer or other types of cancer.”

Patients will have a much better prognosis if they are diagnosed early. Data observed by Cancer Research UK indicates that nearly 90% of patients diagnosed at Stage 1 survived the disease for at least one year, compared to just 19% for those diagnosed at Stage 4.

“It’s too early to know the impact yet,” she said. “But we do expect there to be a huge impact.”

Build Back Better: ‘Not Ambitious Enough’

The process of ‘building back better’ does not go far enough, Harvard T.H. Chan School of Public Health’s Dean, Michelle Williams, said.

Building back better refers to a process of economic recovery from COVID-19 that avoids destructive investment patterns: namely, investments that endanger biodiversity, which is linked to zoonotic diseases jumping species.

“What COVID has done is really show how weak global public health infrastructure can bring us to our knees,” she said.

“To build back better is [to] first recognise the importance and value of public health and invest accordingly. That means properly investing in global governance of public health leadership [and] making the structure nimble and equipped.”

An interim report by the Independent Panel on Pandemic Preparedness and Response, published last week, determined that WHO’s COVID-19 response was too slow, and was hampered by a lack of resources and a damning lack of authority among its member states.

“We’re not being remotely ambitious enough,” Sands said. “This year we are deploying about US$4.7 billion on HIV, TB and malaria to mitigate the collateral damage … we need another $5 billion. And that’s the Global Fund alone.”

And the global ambition for economic recovery, which is “currently shaped as getting back to [a] pre-pandemic” scenario, is “not good enough”, Mitchell added. “Because we weren’t doing well enough before COVID.”

Image Credits: The Global Fund.